Glottic Sulcus

A degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal cord. The lips of a glottic sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.

A glottic sulcus may be overlooked unless one is familiar with this entity. To paraphrase eminent French laryngeal microsurgeon Dr. Marc Bouchayer, these lesions are diagnosed much more frequently once you know about them than before. At present, aside from having the patient coexist peacefully with this problem via voice therapy and other measures, surgery is the primary treatment modality.


Photos:

Glottic Sulcus, before and after surgery

Visual Portfolio, Posts & Image Gallery for WordPress
a partial ring of capillaries around the glottic sulcus

Glottic sulcus, before surgery (1 of 3)

Glottic sulcus, normal light, showing retained material/ granulation emerging from within the sulcus. There is a partial ring of capillaries around the sulcus on the right (left of photo), but no significant vessels within the sulcus (also see next photo).
Glottic sulcus in narrow-band illumination

Glottic sulcus, before surgery (2 of 3)

Same patient. Narrow-band illumination shows the vascular markings more clearly.
Glottic sulcus after surgery

Glottic sulcus, after surgery (3 of 3)

Same patient, after surgery. Note microvasculature where it was not present prior to operation; especially noticeable on the right side (left of photo). There is a now a continuous layer of mucosa.

Congenital glottic sulcus and bowing, before and after injection

Visual Portfolio, Posts & Image Gallery for WordPress
Glottic sulcus

Glottic sulcus (1 of 10)

This young patient has a husky, air-wasting voice quality. View of the vocal cords, in breathing position. An abnormality can be seen, especially on the right cord (left of photo, at arrows).
Glottic sulcus in strobe lighting

Glottic sulcus (2 of 10)

Under strobe lighting, during phonation, open phase of vibration, at a normal speech frequency (pitch), showing an unusually large amplitude of vibration.
Closed phase of vibration

Glottic sulcus (3 of 10)

Closed phase of vibration, but not quite closing completely.
Glottic sulcus on both cords

Glottic sulcus (4 of 10)

Closer view, during inspiratory phonation, reveals very clearly that this patient has sulci on both cords, with the open pocket especially visible on the right cord (left of photo).
Sulcus with bowing

Sulcus with bowing, just prior to injection (5 of 10)

At the prephonatory instant, under standard light. In addition to a sulcus, this patient has congenital bowing.
Glottic sulcus with bowing

Sulcus with bowing, just prior to injection (6 of 10)

Phonation, under standard light, at the pitch E-flat 4 (~311 Hz). Notice in particular the generous width of the zone of vibratory blurring, which correlates with the flaccid, large-amplitude vibration seen in photo 2's strobe view.
Voice gel injection

Voice gel injection (7 of 10)

The left vocal cord (right of photo) is now being injected with voice gel. The injection is centered so that the undersurface, free margin, and ventricle all show evidence of bulging.
Voice gel injection

Voice gel injection (8 of 10)

The other vocal cord is now being injected.
After the injection

After the injection (9 of 10)

After voice gel injection is completed. At the prephonatory instant. Notice the reduced gap between the vocal cords (compare with photo 5).

After the injection (10 of 10)

During phonation, under standard light, again at E-flat 4 (~311 Hz). The width of vibratory blurring is reduced (compare with photo 6), consistent with reduced amplitude of vibration and reduced air-wasting.

Glottic Sulcus

Visual Portfolio, Posts & Image Gallery for WordPress
Faint line of glottic sulcus

Glottic sulcus, closed (2 of 2)

Faint line of glottic sulcus at arrow. Essentially the result of a cyst that has completely emptied of its contents (OR).
instrument holds one lip of the sulcus

Glottic sulcus, open (1 of 2)

Same patient, while instrument holds one lip of the sulcus, splaying it open to reveal the empty “pocket” (OR).
Visual Portfolio, Posts & Image Gallery for WordPress
Bilateral glottic sulcus

Glottic sulcus (1 of 2)

Bilateral sulci, more subtle; opening closer to the free margin.
tiny opening of the sulcus right at the margin of the left vocal cord

Glottic sulcus (2 of 2)

Same patient. Note the tiny opening of the sulcus right at the margin of the left vocal cord.
Visual Portfolio, Posts & Image Gallery for WordPress
Mucosal bridge / glottic sulcus

Glottic sulcus (1 of 2)

Mucosal bridge / glottic sulcus.
Glottic sulcus

Glottic sulcus (2 of 2)

Same patient, showing sulci (arrows) under strobe light.
Visual Portfolio, Posts & Image Gallery for WordPress
Glottic sulcus

Glottic sulcus (1 of 2)

Note that the "lips" of the glottic sulcus are open; compare to image #2. Also see the video for this.
Glottic sulcus

Glottic sulcus (2 of 2)

Note that the "lips" of the glottic sulcus are closed; compare to image #1. Also see the video for this.
Visual Portfolio, Posts & Image Gallery for WordPress
Shallow sulcus

Glottic sulcus (1 of 1)

Shallow sulcus, left vocal cord (right of image), at the free margin.

Glottic Sulcus and Glottic Furrow

Visual Portfolio, Posts & Image Gallery for WordPress
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (1 of 4)

This patient has a glottic sulcus on the left vocal cord (right of image) and a glottic furrow on the right vocal cord.
inspiratory phonation with glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (2 of 4)

Same patient, inspiratory (breathing in) phonation. Note how this accentuates the opening of the sulcus on the left vocal cord (right of image).
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (3 of 4)

Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and furrow.
Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (4 of 4)

Same patient. Compare with photo 3 to observe the vibratory appearance of the sulcus and furrow.

Glottic Sulcus Operation

Visual Portfolio, Posts & Image Gallery for WordPress
Glottic sulcus

Glottic sulcus operation (1 of 7)

Preoperative exam image, the glottic sulcus is indicated by arrows. (In the remaining photos the view of the larynx is reversed, so the affected area will be on the opposite side of the photo).
inflammation, capillary prominence, and margin swelling

Glottic sulcus operation (2 of 7)

Initial operative view showing inflammation, capillary prominence, and margin swelling of the right vocal cord. The sulcus is indicated by arrows, but can be seen much more easily in the next photo.
instrument causes the sulcus to gape open

Glottic sulcus operation (3 of 7)

Rolling the cord laterally with an instrument causes the sulcus to gape open.
needle is inserted lateral to the still-gaping sulcus

Glottic sulcus operation (4 of 7)

A needle is inserted lateral to the still-gaping sulcus to infiltrate for both vasoconstriction and hydrodissection.
epithelial-lined pocket is nearly dissected

Glottic sulcus operation (5 of 7)

The epithelial-lined “pocket” is nearly dissected free from the interior of the cord.
medial and lateral mucosal flaps are retracted

Glottic sulcus operation (6 of 7)

The medial and lateral mucosal flaps are retracted to show the deep layer from which the epithelial-lined pocket was dissected.
Incision line after successful surgery

Glottic sulcus operation (7 of 7)

At completion of surgery, there is no loss of surface mucosa, and only an incision line.

Surgical Removal of Glottic Sulcus

Visual Portfolio, Posts & Image Gallery for WordPress
cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa

Surgical removal of glottic sulcus (1 of 4)

At beginning of surgery, the cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa. Line of the sulcus is seen proceding anteriorly from the point of the needle entry.
elliptic incision around the lips of the sulcus

Surgical removal of glottic sulcus (2 of 4)

An elliptic incision has been made around the lips of the sulcus.
Right-curved alligator clip tents the medial mucosal flap

Surgical removal of glottic sulcus (3 of 4)

Right-curved alligator clip tents the medial mucosal flap. Arrows indicate the fine line that represents the opening into the sulcus. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament.
gossamer mucosa is tented medially to show remaining flexibility

Surgical removal of glottic sulcus (4 of 4)

After the sulcus pocket is removed, gossamer mucosa is tented medially to show remaining flexibility. The voice is expected to be improved, but normal upper voice capabilities are only sometimes achieved.

Open Cyst or Sulcus?

Visual Portfolio, Posts & Image Gallery for WordPress
nuances besides the vascularity and hyperemia

Hoarse voice (1 of 4)

This music teacher has been hoarse for several years. Look for the nuances besides the vascularity and hyperemia, right cord (left of photo) greater than left (right of photo). The next photo makes the findings more obvious.
pearl of keratin emerging from the faintly grey sulcus

Open Cyst Definition (2 of 4)

Under narrow band light, note the “pearl” of keratin emerging from the faintly grey sulcus outlined by the tiny dotted lines. When a lot of keratin is retained, we call this an open cyst; when little or none, just a sulcus. Dotted line on the left vocal cord (right of photo) indicates the middle of the sulcus on that side.
lateral lip of the sulcus

Closed phase (3 of 4)

Closed phase of vibration under strobe light at A4 (440 Hz). The right sided sulcus is concealed, but the left side is more visible. The white line (superimposed dots) represents the lateral lip of the sulcus.
medial and lateral lips with a linear depression between them

Open phase (4 of 4)

Open phase of vibration at the same pitch shows medial and lateral lips with a linear depression between them.

Sulcus and Segmental Vibration

Visual Portfolio, Posts & Image Gallery for WordPress
lateral lip of her glottic sulci

Glottic sulci (1 of 4)

Closed phase of vibration, strobe light, at G3 (196 Hz) in a young high school teacher/ coach who is also extremely extroverted. Faint dotted lines guide the eye to see the lateral lip of her glottic sulci.
full-length oscillation

Open phase (2 of 4)

Open phase of vibration at the same pitch, showing full-length oscillation.
closure of the short oscillating segment

Closed phase (3 of 4)

Closed phase of vibration at E-flat 5 (622 Hz). Arrows indicate closure of the short oscillating segment.
tiny segment opens significantly

Segmental vibration (4 of 4)

Open phase of vibration also at E-flat 5, Only the tiny segment opens significantly. As expected the patient’s voice has the typical segmental “tin whistle” quality.

Open Cyst and Sulcus; Normal and Segmental Vibration

Visual Portfolio, Posts & Image Gallery for WordPress
Breathing position of the vocal cords of a very hoarse actor

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.
right sulcus

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.
pen phase of vibration

Open phase, strobe light (3 of 6)

Under strobe light, open phase of vibration at A3 (220 Hz). The full length of the cords participate in vibration.
closed phase

Closed phase, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.
only the anterior segment is opening for vibration

Segmental vibration (5 of 6)

At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.
closed phase of vibration involves only the tiny anterior segment of the vocal cords

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.

Glottic Furrow—Not Just Bowing and Not Glottic Sulcus

Visual Portfolio, Posts & Image Gallery for WordPress
Bowing vocal cords with furrows

Bowing vocal cords with furrows (1 of 4)

This middle-aged man's voice has become increasingly husky and weak across many years. In retrospect, it was never a "strong" voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.
Closed phase

Closed phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.
Open phase

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but "furrow" would be the better definition, as seen in the next photo.
Lower pitch reveals furrow

Lower pitch reveals furrow (4 of 4)

At lower pitch, the amplitude of vibration is larger and the right cord (left of photo) reveals more clearly that the the linear depression is a wide furrow, not a slit-like sulcus.

Mottled Vocal Cord Mucosa May Hide Glottic Sulci

Visual Portfolio, Posts & Image Gallery for WordPress
Vocal cord swelling

Vocal cord swelling and mucosa (1 of 4)

This young “dramatic” soprano is also a bona fide vocal overdoer. Her vocal capabilities have been diminishing for over two years. In this medium-range view, note the rounded swelling of the right cord (left of photo), but more significantly as we shall see, the increased vascularity and mottled appearance of the mucosa.
projecting polypoid swelling

Same view under strobe light (2 of 4)

Under strobe light, at open phase of vibration at C#5 (523 Hz), we see a projecting, polypoid swelling of the right vocal cord, but not yet the more difficult problem.
mismatch of the vocal cord margins

Closed phase (3 of 4)

Closed phase of vibration, at the same pitch of C#5 shows the mismatch of the vocal cord margins. Is this the entire explanation for this patient's hoarseness? Read on.
open mouth of a right-sided glottis sulcus

Glottic sulcus is visible (4 of 4)

At close range and high magnification, the open mouth of a right-sided glottis sulcus is seen. This side can be operated safely due to the excess, thick mucosa and would be expected to improve the margin match. On the left (right of photo), a sulcus is also seen, but the thinner mucosa makes successful surgery on the left more challenging.

A Case That Clearly Shows the Relationship Between Cyst & Sulcus

Visual Portfolio, Posts & Image Gallery for WordPress
white lesion on right vocal cord

White Lesion on Right Vocal Cord (1 of 6)

This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).
White Lesion Under Strobe Light

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.
lesion in closed phase of vibration

White Lesion Under Strobe Light (3 of 6)

The closed phase of vibration shows more clearly the depression from which the lesion is protruding.
White Lesion Removed

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.”
trough from which the lesion was removed

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.
closed phase of vibration post removal

Vocal Cords without Lesion (6 of 6)

The closed phase of vibration. Compare with photo 3.

Nuances of Endotracheal Tube Injury

This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).

Visual Portfolio, Posts & Image Gallery for WordPress

Maximum glottic opening (1 of 8)

Is it paralysis, as diagnosed elsewhere? At a fairly distant view, the maximum opening between the vocal cords at any phase of breathing appears to be approximately a 4mm glottic opening.

Undersurface mucosa indraws (2 of 8)

When the patient inspires rapidly with tracheotomy tube plugged, the vocal cord undersurface mucosa indraws (grey bands at dotted lines), further narrowing the glottic chink. One sees a faint suggestion of breathing tube injury (divot) at the arrow. Notably, there is a very low pitched rumbling sound heard that does not come from the glottis.

Phonation (3 of 8)

During phonation, the cords approximate fully, and in fact the voice is remarkably normal-sounding and she even has an excellent upper range.

Posterior commissure divot (4 of 8)

At close range while breathing with trach plugged, the posterior commissure divot subtly visible in Photo 2 is confirmed. A divot in the right posterior cord “always” indicates that the tube was taped to the left corner of the mouth. The patient’s mother confirmed that this was so.

Further evidence of scarring (5 of 8)

Angling farther posteriorly, additional evidence of inter-arytenoid and possible joint capsule injury is seen. Faint dotted lines outline this area. The problem is not bilateral vocal cord paralysis but posterior commissure scarring, tethering the arytenoids together.

View into trachea (6 of 8)

Looking now into the subglottis and trachea, there is narrowing only at trach entry site, accentuated functionally because the membranous trachea (MT) moves in and out with respiratory phase.

Vibration of trachea (7 of 8)

When the patient plugs the trach tube and inspires rapidly, the deep rumbling sound is again heard, and comes from vibration of the membranous trachea indrawing (arrows) and vibrating (zigzag line).

Open trachea beyond the tube (8 of 8)

A view past the tip of the trach tube shows no secondary area of tracheal stenosis.

The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.


Glottic Sulcus: Laryngeal Videostroboscopy
Glottic sulcus is a degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal fold. The lips of the sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.
Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.

Stenosis

Abnormal narrowing of a passageway in the body. At our practice, stenosis typically refers to narrowing in the breathing passage, such as for narrowing in the glottic, subglottic, or tracheal areas.

Stenosis in the airway can be the result of prolonged endotracheal intubation, external trauma such as gunshot wound, crush injury, or tracheotomy, an inflammatory or auto-immune process, surgical resection of part of the airway for tumor, or other causes. Persons with airway stenosis will note a reduced capacity for exercise. Often the clinician hears noisy breathing on inhalation, especially when the patient is asked to fill the lungs quickly. Esophageal stenosis gives symptoms of difficulty swallowing solids more so than liquids.


Photos of Stenosis:













 



















Nuances of Endotracheal Tube Injury

This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).

Visual Portfolio, Posts & Image Gallery for WordPress

Maximum glottic opening (1 of 8)

Is it paralysis, as diagnosed elsewhere? At a fairly distant view, the maximum opening between the vocal cords at any phase of breathing appears to be approximately a 4mm glottic opening.

Undersurface mucosa indraws (2 of 8)

When the patient inspires rapidly with tracheotomy tube plugged, the vocal cord undersurface mucosa indraws (grey bands at dotted lines), further narrowing the glottic chink. One sees a faint suggestion of breathing tube injury (divot) at the arrow. Notably, there is a very low pitched rumbling sound heard that does not come from the glottis.

Phonation (3 of 8)

During phonation, the cords approximate fully, and in fact the voice is remarkably normal-sounding and she even has an excellent upper range.

Posterior commissure divot (4 of 8)

At close range while breathing with trach plugged, the posterior commissure divot subtly visible in Photo 2 is confirmed. A divot in the right posterior cord “always” indicates that the tube was taped to the left corner of the mouth. The patient’s mother confirmed that this was so.

Further evidence of scarring (5 of 8)

Angling farther posteriorly, additional evidence of inter-arytenoid and possible joint capsule injury is seen. Faint dotted lines outline this area. The problem is not bilateral vocal cord paralysis but posterior commissure scarring, tethering the arytenoids together.

View into trachea (6 of 8)

Looking now into the subglottis and trachea, there is narrowing only at trach entry site, accentuated functionally because the membranous trachea (MT) moves in and out with respiratory phase.

Vibration of trachea (7 of 8)

When the patient plugs the trach tube and inspires rapidly, the deep rumbling sound is again heard, and comes from vibration of the membranous trachea indrawing (arrows) and vibrating (zigzag line).

Open trachea beyond the tube (8 of 8)

A view past the tip of the trach tube shows no secondary area of tracheal stenosis.

The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.


Videos of Stenosis:

Tracheal Stenosis: Before and After
In this video, trachea (windpipe) blockage causes shortness of breath until the narrowed segment is removed. You will see views of the trachea before and after surgical repair.
Post-Radiation Hypopharyngeal Stenosis
People with larynx or pharynx (voice box or throat) cancer often undergo radiation therapy as part of their treatment regimen. An uncommon complication is stenosis (narrowing, scarring) of the entrance to the upper esophagus at the junction of the throat and esophagus. This video provides an example of this disorder.

Segmental Vibration

In the normal larynx, both chest and falsetto (head) registers are produced by vibration of the anterior 2/3 of the vocal cords. The posterior 1/3 is “inhabited” by the arytenoid cartilage and does not vibrate.

In certain pathological circumstances such as displayed in the photo sequences below, only a small part of the vocal cords vibrates.

This segmental vibratory phenomenon is typically seen in vocal cords that are damaged—such as by vocal nodules, polyps, cyst, scarring, etc. In such persons, upper voice is typically particularly impaired, until, as the person continues to try to ascend the scale, suddenly a crystal-clear “tin whistle” kind of voice emerges and may continue upwards to very high pitches.

Some in the past have talked about flagelot, flute, bell, or whistle register.  We suspect that this was in the days before videostroboscopy and at least in some cases may have been segmental vibration.

The best way to determine if what sounds like a “tin whistle” upper voice extension is due to segmental vibration is by videostroboscopic examination during that kind of phonation. The other way is for the individual to produce their “tin whistle” kind of voice very softly and then try to crescendo. If full length vibration, smooth crescendo will be possible. If segmental, there will be a sudden “squawk” as the vocal cords try to go (unsuccessfully) from segmental to full-length vibration.


Photos:







SLAD-R

SLAD-R (Selective laryngeal adductor denervation-reinnervation). This procedure was introduced by Dr. Gerald Berke of UCLA in the late 1990’s. It is a surgical option for adductory spasmodic dysphonia. The concept is to sever the anterior branch of the recurrent laryngeal nerve. This denervates the spasming laryngeal adductors (particularly thyroarytenoid and lateral cricoarytenoid muscles). The squeezed, strained quality and/ or “catching, cutting out, stopping” of the voice are replaced initially with an extremely breathy and weak voice. This initially weak voice is analogous to what one might sound like after a Botox injection that is far too high a dose. To return strength to the voice, a branch of the ansa cervicalis nerve that normally supplies some relatively “unimportant” neck muscles is anastomosed (connected) to the severed nerve. It takes 3 months to a year for tone to begin to return to the adductory muscles. Since the “unimportant” neck muscles were not affected by the dystonia, the hope is that the new nerve supply to the laryngeal muscles may not be affected by dystonia.


Photos:



Videos:

One Man’s Experience Over Time with SLAD-R
SLAD-R is a surgical alternative to ongoing “botox” injections for treatment of adductory spasmodic dysphonia. The surgery involves intentionally cutting the nerves that close the vocal cords for voice and reconnecting a different nearby nerve supply (reinnervating the nerves). This surgery requires the patient’s willingness to endure an extremely breathy voice for many months after the procedure, while awaiting reinnervation.

Translucent polyp

Some polyps are covered by mucosa that is opaque. Some are filled with blood (hemorrhagic polyp). On the other hand, some have a thin and delicate mucosa, and a watery content that is not transparent, yet transmits some light. Unlike a blister, which they could be construed as resembling, and which typically resolves itself, most translucent polyps end up requiring surgery for their resolution.


Photos of translucent polyps:





Phonatory gap

When the vocal cords fail to close during phonation. A phonatory gap may be seen in patients who have muscle tension dysphonia, vocal cord paresis or paralysis, loss of tissue, or vocal cord flaccidity.

In addition, however, a phonatory gap occasionally occurs in patients who have none of the above conditions. In this type of case, the patient will struggle with onset delays, but delays that “pop” followed by relatively clear voice rather than the scratchier or hoarser-sounding onset delays associated with vocal cord mucosal swelling. Also, if asked to perform our vocal cord swelling checks, such a patient will tend to struggle more with the “Happy birthday” task than the descending staccato task (the opposite is true for patients with mucosal swelling).


Photos:



Pharyngeal Paralysis

The pharynx (loosely “throat”) has a “foodway” function to convey food and liquid from the mouth to the esophagus. It also serves as part of the “airway,” also from mouth into the larynx and trachea. These foodway/airway functions are kept separate so food and liquid do not enter the airway towards the lungs. At the moment of swallowing, vocal cords clamp firmly together and epiglottis drops over the entrance of the larynx to divert food and liquid into the esophagus. During each swallow, lasting perhaps a second, breathing is briefly suspended. Once the food/liquid has gone by, the larynx re-opens and breathing resumes.

A thin sheet of muscle surrounds the pharynx, and squeezes to narrow the pharynx and help to propel swallowed material. That contraction lasts for approximately one second, each time the person swallows. The muscle is innervated bilaterally by the pharyngeal branch of the vagus nerve and so one side or both sides can be paralyzed by tumor, fracture at the base of the skull, viral injury, etc.

This diagnosis is often overlooked, because clinicians may not be clear on how to make the diagnosis. The best way is to obtain a clear panoramic view of the laryngopharynx as seen in the photo series below, and ask the patient to produce a very high pitch. This maneuver “recruits” contraction of the pharynx outside of the act of swallowing and allows the examiner to see clearly the difference in the contraction of the two sides. The paralyzed side is pulled to the non-paralyzed side, again as seen below.

Some with unilateral pharynx paralysis can compensate and continue to swallow (with limitations). Others are completely unable to surmount the impediment of this kind of paralysis.




Croup

Also known as laryngotracheitis or laryngotracheobronchitis, croup1 is a primarily pediatric viral disease affecting the larynx and trachea. Though it may resemble a simple cold at first, the infection causes a loud barking cough and stridor (unusual, high-pitched breathing noises indicating partial airway obstruction). The majority of cases are caused by parainfluenza viruses (types 1, 2, and 3) but a variety of other viruses can lead to croup symptoms.

The central problem for patients with croup is the swelling of the subglottic region of the larynx, which is the narrowest part of the airway in children. It can vary in its severity and can last anywhere from three days to two weeks. Most patients do not require hospitalization, as home treatment or prescribed antibiotics or steroids are typically sufficient.


Croup, aka Laryngotracheitis:

Visual Portfolio, Posts & Image Gallery for WordPress
Croup

Croup, aka laryngotracheitis (1 of 4)

Though croup is most often seen in children, this woman developed a barking cough and mild, non-anxiety provoking stridor in the context of an upper respiratory infection. In this panoramic view note in particular the prominence and redness of the conus part of the vocal cords (indicated by white lines).
laryngotracheitis

Croup, aka laryngotracheitis (2 of 4)

Closer view. Dotted lines signify normal airway diameter.
redness and narrowing of the posterior subglottic airway

Croup, aka laryngotracheitis (3 of 4)

Even closer view showing redness and narrowing of the posterior subglottic airway.
Croup

Croup, aka laryngotracheitis (4 of 4)

View within the posterior subglottic narrowing.

  1. Meyer, Anna. “197. Pediatric Infectious Disease” Cummings Otolaryngology Head and Neck Surgery. Ed. Paul Flint. 6th ed. Vol. 3. Philadelphia, PA: Elsevier, 2015. 3045-3054. 

Chondroma

Chondroma is a benign growth composed of cartilage cells.


Chondroma of thyroid cartilage

Visual Portfolio, Posts & Image Gallery for WordPress
CT scan of the larynx, showing the thyroid cartilage

CT scan of the larynx (1 of 4)

CT scan of the larynx, showing the thyroid cartilage (outlined by gray dotted lines) and an abnormality deforming the thyroid cartilage on one side (between the white arrows). Note how the thyroid cartilage bulges on that side, as compared with the opposite side, and the black speck which indicates varying densities in the cartilage.
Chondroma of thyroid cartilage

Endoscopic View of the Larynx (2 of 4)

Same patient, endoscopic view of the larynx, again showing the abnormality (at arrows). Here the abnormality looks similar to a saccular cyst, but the scan (and subsequent biopsy) shows that it is cartilaginous and a chondroma, not chondrosarcoma.
Closer view of the chondroma

Chondroma of thyroid cartilage (3 of 4)

Closer view of the chondroma, showing an almost bi-lobed appearance.
Chondroma of thyroid cartilage

Left Vocal Cord Sits Lower Then the Right (4 of 4)

Under strobe lighting, which shows that the left vocal cord (right of photo) is apparently at a lower level than the opposite cord.

Pharyngocutaneous fistula

The leaking of saliva outside of the pharynx (“throat” part of the swallowing passage) through a defect in the pharyngeal mucosa lining. This may occur transiently in up to 20% of persons who have undergone total laryngectomy, with the sixth postoperative day the peak time of incidence. Prior radiation therapy seems to increase the risk of fistulization.

Traditionally, the treatment was to make a midline incision directly, insert a penrose drain, and then use pressure dressings. Modern treatment uses suction drains to control salivary leakage and allow the rest of the skin flap to adhere to the neck1. Then, the drain is removed, shortened, and replaced a series of times to allow the tract to close from top to bottom.




  1. Bastian RW, Park AH. Suction drain management of salivary fistulas. Laryngoscope. 1995;105(12 Pt 1):1337-41.