Swelling Checks to Detect Vibratory (Overuse) Injury to the Surface Tissue (Mucosa) of the Vocal Cords

 

 

Definition: Vocal tasks (swelling checks) that detect acute or chronic vocal fold mucosal injury reliably; Secondarily, they can also detect gaps between otherwise normal folds.
Purpose /rationale: To provide persons with a way to detect mucosal trouble for themselves. We are in effect “taking all of the clothes off the mucosa.”
Who they are for: Anyone who uses the voice extensively or vigorously—particularly vocal overdoers.*
What they are not for: Voice training or performance.
When they should be done: When first learning the tasks, they should be done often until the concept of one’s mucosal ceiling is understood (see below). Once both proficiency and ceiling are established, the tests require 20 seconds or less both morning and evening.

TEST I: “HAPPY BIRTHDAY”

  1. In your upper voice range, sing the first phrase of “Happy Birthday” as softly as you can, using a “boy soprano pianissimo.” Resist the temptation to “make it work” by getting louder!
  2. Repeat the phrase at progressively higher pitches.
  3. Verify carefully the pitch at which you falter (onset delays or air escape) or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.
  4. If your mucosa is normal, the “soft voice” and “loud voice” ceilings should be about the same.
  5. If your mucosa is abnormal, the “loud” ceiling should be higher than the “soft.”

TEST II: STACCATO

  1. Sing again “boy soprano pianissimo” using the descending staccato figure so so so so so fa mi re do
    (5-5-5-5-5-4-3-2-1; e.g. G-G-G-G-G-F-E-D-C) Attack each note precisely in the middle of the continuum
    between an aspirated ho and a coupe de glotte. In other words, lightly, precisely, and with a little bounce.
  2. As for “Happy Birthday,” repeat at progressively higher pitches.
  3. Again carefully verify the pitch at which you experience onset delays or air escape or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.

COMMON QUESTIONS

My mucosal ceiling is higher when I do the staccato exercise than it is when I do “Happy Birthday.” What does that mean?

Though needing verification via careful laryngeal examination, this phenomenon suggests that a small gap between the folds, rather than swelling, is the problem.

My mucosal ceiling is higher when I do the “Happy Birthday” exercise than it is when I do staccato. What does that mean?

Again needing verification, this phenomenon suggests a mucosal disturbance rather than a gap as the explanation.

I can figure out my mucosal ceiling easily enough, but how do I know if it is normal?

This can be answered best at the outset by individuals who can compare your performance with that of hundreds of others to whom they have applied these tests (e.g. laryngologist, speech pathologist, voice teacher). It is also helpful at the beginning to correlate your mucosal ceiling with high quality visualization of the vocal folds.

What if my ceiling isn’t normal as compared to others?

The swelling tests are nevertheless just as valuable! Here’s how: Suppose an individual’s initial mucosal ceiling is abnormal because of small vocal nodules, but the person is happy with the voice’s capabilities. Here, the swelling tests can be monitored to help the individual prevent additional mucosal injury, by not allowing the ceiling to descend any further. A different person whose initial ceiling is abnormal might be unhappy with
perceived limitations due to mucosal injury. Now, ongoing use of the swelling tests can confirm the benefits of medical, behavioral (voice therapy) or, eventually, surgical treatments, because the ceiling will rise with successful treatment. Furthermore, these tests can help to avoid recurrent injury.

What if I notice that my ceiling is abnormal (lower) as compared to my usual?

First, consider recent voice use for the possibility that it was “too much.” If so, and/or if the ceiling
remains lowered on subsequent trials of the tests later in the day, “back off” by reducing voice use
until the ceiling returns to your usual pitch, whether “normal” as compared to other persons or not.
Women: Some may find that the ceiling lowers routinely during pre-menstrual days, but returns to normal in a few days.

Do I need to cancel everything until the ceiling recovers?

This depends on the severity of the lowering of the ceiling. Generally, however, careful strategy concerning amount and manner of voice use during this time will allow the mucosa to recover while you continue to work or perform.

Are there common pitfalls in use of the swelling tests?

First and foremost, is the tendency to adjust how the voice is produced when the voice begins to falter. A singer will, for example, unconsciously get a bit louder or use a slight glottal attack to “make it work,” thereby reducing the sensitivity of the tasks. Another might be to perform them without a pitch reference at hand, so that the value of comparing with one’s known “ceiling” pitch is lost. A third might be to become a bit too obsessive and easily “spooked” with any ceiling change. And finally, comes the tendency to “lose the habit!”

* Vocal overdoer: Defined as an individual with both of the following:
  1. A high propensity to use the voice. Generally, “sixes and sevens” on a 7-point (maximum) intrinsic talkativeness scale.
  2. A high extrinsic opportunity or invitation to use voice, based on family, social, vocational, and avocational considerations.

Motivated Laryngeal Examination

A “Motivated” laryngeal examination is an examination in which the clinician “pushes” the larynx to reveal its secrets. If topical anesthesia is used, this can be done without undue discomfort to the patient, and laryngeal images can be close and clear rather than far and fuzzy.


Photos:

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Motivated examination (1 of 4)

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

Motivated examination (2 of 4)

At closer range, two findings become evident. First, permanent capillary reorientation is seen (inside the white dotted oval), which is typical after superficial cordectomy; note the more jagged and left-right capillary patterns. Second, tiny points of leukoplakia (inside the green dotted oval) become evident on the opposite vocal cord. The bright white spot in the photo is just a light reflection.

Capillary and leukoplakia (3 of 4)

After vigorous throat clearing, and using a view that is closer still, capillary and leukoplakia findings are confirmed. Note that the brilliant white light reflection is now in a different location.

Leukoplakia (4 of 4)

Still closer view, again confirming the tiny patches of leukoplakia.

Subtle Papillomas and the Importance of A Motivated Examination

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Standard light, HPV-6 infection (1 of 4)

Breathing position, standard light in a young woman with longstanding HPV-6 infection. Voice remains quite good, many months after her last microsurgery with cidofovir injection. The only obvious “lesion” is posterior right cord (left of image) but the characteristic punctate vascular marks are not seen. The black lines are purely for use to orient photo 4.

Stobe light, vocal cord margin irregularity (2 of 4)

With such a clear voice, this prephonatory instant under strobe light reveals a surprising degree of vocal cord margin “serpentine” irregularity. Black lines again support orientation with photo 4.

Narrow band light, vascular marks seen (3 of 4)

At very close range and also using narrow band light, the tiny punctate vascular marks are seen in the lesion first seen in photo 1. Faint vascularity like that demonstrated here can be a correlate of relatively stable, inactive disease, which has clinically been the case here.

Narrow band light, papilloma formation (4 of 4)

This narrow band view includes only the anterior half of the vocal cords from the black lines of photos 1 and 2 to the anterior commissure (at x). Inside the faint circles, note the vascular markings that suggest papilloma formation to explain the serpentine margin.

Motivated Examination for Diagnostic Precision

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Chronic hoarseness, nodules suspected (1 of 2)

A person with chronic hoarseness. Working from a “typical” laryngeal examination photo alone, one might suspect vocal nodules.

Arrows point to papillomas (2 of 2)

By going to the trouble of getting an extremely close-range view such as this one, requiring use of topical anesthesia, one can see what appear to be papillomas, with stippled vascular effect associated with HPV-related disease. RRP is in fact the biopsy-proven diagnosis and papillomas are indicated by arrows.

Motivated Airway Examination Avoids Further Surgery

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Marginal airway (1 of 4)

This woman underwent radiotherapy for larynx cancer several decades earlier. Some years ago, progressive post-radiation fibrosis had nearly fixed the vocal cords in the midline and airway was marginal. A laser posterior commissuroplasty was done as an alternative to tracheotomy. During a recent hospitalization for pneumonia elsewhere, she was told that her airway was inadequate; she returned for examination for this reason. During this kind of distant view, her airway does indeed look marginal.

Airway at close range (2 of 4)

At close range using topical anesthesia, with the patient exhaling, her airway appears adequate. The dotted line is where the margin of the cords would be if the divots had not been removed.

Forced inspiration (3 of 4)

Forced inspiration draws the vocal cord mucosa medially to narrow the airway, and inspiratory noise is heard, but the posterior divots maintain a small but adequate airway and time to fill is only mildly prolonged.

Alternative to tracheotomy (4 of 4)

During phonation, the divots removed from the posterior vocal cords are more clearly seen. Voice is air-wasting, airway is of course suboptimal, but no tracheotomy or additional laser commissuroplasty is needed.

Siren

A siren is an uninterrupted sound that begins very low in a person’s vocal range and ascends to a very high pitch, sometimes the highest possible pitch that person can produce. A single siren could also go from low to high and back to low one or more times without interruption. A clinician might ask a patient to perform a siren during the vocal capability battery in order to assess pitch range capability or even vocal skill.

Projected Voice

Projected voice is one that is perceptibly “thrown” or “called out,” as when talking to a group of 20 or more people. A clinician might ask a patient to project the voice during the vocal capability battery in order, for example, to reveal weakness not evident or only slightly apparent at normal speaking voice volume, to detect vocal inhibition, or to unmask a nonorganic voice disorder.


Laryngology 401: PCA-only Paresis, but the Actual Voice Problem Is Spasmodic Dysphonia

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Sense of instability (1 of 3)

This person had a major voice change after thyroidectomy for a large goiter. Within 2 months, voice recovered fully--except for a sense of instability. The PCA-only paresis is not the explanation because voice-making muscles (TA + LCA) are intact. And in fact vocal capability testing shows that both yell and projected voice are normal. The visual finding here of vocal cord bowing and capacious ventricle do not count as a breathing position finding with PCA-only paresis due to the unopposed action of LCA muscle, combined with an uncontracted TA muscle, both of which cause pseudo-bowing.

Vibratory amplitude (2 of 3)

During phonation under strobe light, with TA tensing, "bowing" disappears. Furthermore the vibratory "blur" at the margin of the left fold (right of photo) is equal to the right (left of photo), telling us that vibratory amplitude is approximately the same on both sides.

Spasm (3 of 3)

An audible/ visible spasm occurs when the right vocal cord jerks laterally for 4 frames (~ 1/8th of a second). The problem isn't PCA weakness on the left (right of photo), but instead an abductory spasm on the right (left of photo), fully mobile cord!

Vocal Commitments

Events or circumstances that permit, invite, or demand much voice use. A person’s vocal commitments could include his or her occupation, childcare, rehearsals and performances, hobbies or even volunteer activities to which a person is highly committed, sports, and so forth. Heavy vocal commitments and innative talkativeness are the two potential sources of vocal overuse and, unsurprisingly, are often seen together.

Vocal Loudness Scale

Vocal loudness scale is a scale from 1 to 7 that we use to describe the loudness of a person’s typical speaking voice as compared with one’s experience of the rest of the human race. For example, someone whose vocal loudness seems to be unexceptional and does not draw any attention to itself—average, in other words—might be considered a “4.” The person who speaks so softly that everyone who encounters him or her has to strain to understand might be a “1.” The person whose voice is (often unconsciously) so loud that one needs to step back or hold the telephone away from the ear might be considered a “7.” See also: disorder of vocal loudness perception.

Narrow-band Illumination

The use of only two narrow wave bands of light (blue and green) during an endoscopic examination, so as to make blood vessels and other tissues in the mucosa more visible. Blood vessels become more visible under narrow-band illumination because both of the wave bands are easily absorbed by hemoglobin in the blood. In addition, the blue and green wave bands in narrow-band illumination each penetrate the tissue to differing degrees, so that blood vessels near the mucosal surface appear as a different color from blood vessels deeper in the tissue.

In the field of laryngology, narrow-band illumination can help an examining clinician to identify the vascular changes that characterize a range of disorders, including recurrent respiratory papillomatosis, capillary ectasia, glottic sulcus, ulcerative laryngitis, and others. It can also help to identify subtle, hazy leukoplakia. The technology, developed by Olympus, is officially called Narrow Band Imaging™. KayPentax offers a different, software-based method for highlighting vascularity and other tissue characteristics, which is called iScan™.


Photos:

Narrow-band vs. Standard Light

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Narrow-band vs. standard light (1 of 2)

Close view of abducted cords, standard light.

Narrow-band vs. standard light (2 of 2)

Same view, but under narrow-band light. Note how the blood vessels are much easier to see. In addition, the right vocal cord (left of image) manifests a small, whitish area of submucosal fibrosis (not true leukoplakia).

Narrow-band vs. Standard Light: Leukoplakia

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Narrow-band vs. standard light: leukoplakia (1 of 2)

With standard light, the leukoplakia on the right vocal cord (left of image) is visible but indistinct, as a hazy, whitish patch.

Narrow-band vs. standard light: leukoplakia (2 of 2)

With narrow-band light, not only the network of blood vessels but also the hazy leukoplakia is much more apparent.
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Narrow-band vs. standard light: leukoplakia (1 of 2)

Diffuse leukoplakia on both vocal cords, as seen under standard light.

Narrow-band vs. standard light: leukoplakia (2 of 2)

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

Narrow-band vs. Standard Light: Capillary Ectasia

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Narrow-band vs. standard light: capillary ectasia (1 of 2)

Standard light reveals dilated capillaries, especially on the left vocal cord (right of image), as well as bilateral vocal nodules.

Narrow-band vs. standard light: capillary ectasia (2 of 2)

Narrow-band light makes the dilated capillaries stand out more clearly.

Narrow-band vs. Standard Light: HPV-induced Lesions

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Narrow-band vs. standard light: HPV-induced lesions (1 of 2)

Standard light reveals a faint stippled vascularity and a general mild inflammatory response (pinkness), indicative of HPV infection. Patients like this are often misdiagnosed with acid reflux.

Narrow-band vs. standard light: HPV-induced lesions (2 of 2)

Narrow-band light makes the stippled vascularity of this patient's HPV-induced lesions much more apparent.

Narrow-band vs. Standard Light: Candida

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Narrow-band vs. standard light: candida (1 of 2)

Under standard light, the candida colonies on this patient's vocal cords (best seen on the right cord, which is left of image) appear vague and hazy.

Narrow-band vs. standard light: candida (2 of 2)

Under narrow-band light, the candida colonies (as well as the vocal cords' vascularity) are much easier to see.

Videoendoscopic Swallowing Study (VESS)

A method of evaluating a person’s swallowing ability by means of a video-documented physical examination, looking from inside the throat. Also called the fiberoptic endoscopic evaluation of swallowing (FEES). The videoendoscopic swallowing study (VESS) is to be distinguished from the videofluoroscopic swallowing study (VFSS), which is an x-ray-based assessment.

How it works:

To perform a VESS, a clinician uses a fiberoptic or distal-chip nasolaryngoscope. The clinician begins by examining the structure and function of the patient’s palate, tongue, pharynx, and larynx, including sensation, if desired. Next, to assess the patient’s swallowing capabilities and limitations, the clinician positions the tip of the nasolaryngoscope just below the nasopharynx and, looking downward into the throat, asks the patient to swallow a series of colored substances with a range of consistencies (e.g., blue-stained water, blue-stained applesauce, and orange-colored crackers).

As the patient swallows these substances, the clinician watches to see if any significant traces remain in or reappear in the space above, around, or within the larynx, rather than disappearing into the entrance to the esophagus. If significant traces remain in view, or if any material spills into the opening of the larynx or down the trachea, the patient may have presbyphagia. If significant traces initially disappear but then re-emerge upward from the esophageal entrance, the patient may have cricopharyngeal dysfunction, with or without a Zenker’s diverticulum.

Benefits of the videoendoscopic swallowing study:

This method has particular value for patients who are bedfast and cannot travel to the radiology suite, or for patients whose swallowing function is rapidly evolving (improving, usually), such as those recovering from a mild stroke. For clinicians experienced with this technique, VESS can also often be used with new patients complaining of dysphagia during the initial consultation as a robust and—depending on patient history—potentially stand-alone method of diagnosis and management. Sometimes, the VESS findings, along with a patient history of solid food lodgment at the level of the cricoid cartilage or cricopharyngeus muscle, will indicate when VFSS should also be obtained to assess for possible cricopharyngeal dysfunction. Even in this latter circumstance, when VFSS is called upon to confirm a suspected diagnosis, VESS will have already oriented the examiner to the nature and severity of the problem. In most follow-up circumstances other than after cricopharyngeal myotomy, VESS is generally more efficient and inexpensive than VFSS.


Photos:

VESS Assesses Equipment, Secretions, then Swallowing Ability

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Part Ia: Palate elevates normally (1 of 7)

This man has symptoms of cricopharyngeus muscle dysfunction (CPD), with frequent lodgment of solid food (never soft or liquid material) at the level of mid-to-low neck. This VESS sequence demonstrates his propulsive or “pitcher” ability. Here in VESS part Ia, palate elevates normally (arrows). Left palate is not drooping and there is no deviation.

Part Ib: phonation (2 of 7)

In Part Ib of VESS, the patient makes voice, to prove normal movement and good closure of the vocal cords. In addition, no secretional pooling is seen in vallecula or pyriform sinuses.

Part Ic: High pitch elicited (3 of 7)

Part Ic: Very high pitch is elicited. Pharyngeal walls contract inward (arrows), closing the pyriform sinuses. Part Ia,b, and c (Photos 1, 2, and 3) verify that there is good function of swallowing equipment, i.e. palate, pharynx, and larynx (and tongue).

Part IIa: applesauce (4 of 7)

Part IIa: Blue-stained applesauce is first, because puree is the “easiest” material for the majority of patients, whatever their diagnosis. Here, one sees only minimal residue after several boluses are swallowed.

Part IIb: cracker (5 of 7)

Part IIb: After an orange (cheese) cracker, lodgment in the vallecula, and…

Part IIb: continued (6 of 7)

...on the pharyngeal walls (arrows).

Part IIc: water (7 of 7)

Part IIc: After several boluses of blue-stained water, all cracker is washed away and there is no blue staining or residue within the laryngeal vestibule, subglottis, or high trachea. Given this man’s CPD symptoms, VFSS may show a cricopharyngeus muscle bar, indicating incomplete relaxation of the upper esophageal sphincter.

Dysphagia / Delayed Swallow Reflex

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Laryngopharynx (1 of 3)

Panoramic view of laryngopharynx before administering blue-stained applesauce.

Dysphagia / Delayed swallow reflex (2 of 3)

Same view after first bolus of blue-stained applesauce. The vallecula fills with material before the swallow “happens”—signifying a delayed swallow reflex.

Hypopharyngeal pooling (3 of 3)

After several rapidly-administered boluses (to assess patient’s “limits”), note hypopharyngeal pooling, but none within the laryngeal vestibule.

Zenker’s Diverticulum

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Zenker's diverticulum (1 of 3)

This view is a moment after a completed swallow of blue-stained applesauce.

Postcricoid area (2 of 3)

Same view, a second later, as blue-stained applesauce emerges from the Zenker's diverticulum upward (toward the camera) into the postcricoid area.

Hypopharynx (3 of 3)

Another second later, applesauce continues to re-emerge into the hypopharynx.

Reflux Into Hypopharynx, Characteristic of Cricopharyngeal Dysfunction

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Reflux into hypopharynx (1 of 3)

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

Water flows into the swallowing crescent (2 of 3)

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

Larynx opens up (3 of 3)

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

Hypopharynx Pooling After Swallow

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Hypopharynx pooling after swallow (1 of 1)

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

Laryngeal Penetration

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Laryngeal penetration (1 of 1)

After the patient swallowed several boluses of blue-stained applesauce, there were traces visible on the laryngeal surface of the epiglottis, indicative of penetration into the earliest part of the airway. By itself, soiling of the laryngeal vestibule to this minor degree does not threaten the person’s ability to eat by mouth.

Zenker’s Diverticulum and VESS

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Zenker’s diverticulum (1 of 4)

This middle-aged woman has had a known Zenker’s diverticulum for several years. She has now reached a point of frustration that has motivated her to proceed with cricopharyngeus myotomy. The series that follows explains some of the reason for her frustration. In this view, the patient has just completed a swallow of her saliva.

Saliva from Zenker's sac (2 of 4)

A few seconds later, saliva begins to return upwards into the post-arytenoid area (at arrow) from the Zenker’s sac.

More saliva (3 of 4)

Less than a second later, more saliva comes upward from the Zenker’s sac.

Forced to re-swallow (4 of 4)

A few seconds later, sufficient saliva has welled up from the sac that the patient is forced to re-swallow, taking her back to the appearance of the first photo in this series, only to begin the same cycle depicted in these four photos again and again.

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

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Vallecular cyst (1 of 4)

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

Evaluation of function (2 of 4)

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

Applesauce residue (3 of 4)

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

Water wash (4 of 4)

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

Pill Lodgment Due to Swallowing Disability

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Lodged pill (1 of 4)

This older woman swallowed a pill that lodged low in her throat. In spite of repeated swallows and attempts at expectoration, she couldn't move it for many hours. On examination a few days later, this superficial ulceration is seen due to mild chemical burn. Note as well the redness of the left arytenoid and pyriform sinus (right of photo).

Trumpet maneuver (2 of 4)

At closer range, while having the patient perform a trumpet maneuver, a well-demarcated superficial ulcer is seen again.

VESS (3 of 4)

Administration of blue-stained applesauce during VESS shows that a partial reason for lodgment may be reduced propulsive strength, indicated by pooling of material in the vallecula.

Incomplete relaxation of CPD (4 of 4)

After sips of blue-stained water, note the fairly organized crescent of pooled water in the pyriform sinuses and post-arytenoid area. This can suggest a functional outlet obstruction caused by incomplete relaxation of the cricopharyngeus muscle (CPD).

Delayed Swallow Reflex: Compare Blue Applesauce and Blue Water

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VESS (1 of 4)

During VESS, blue-stained applesauce falls down to the posterior base of tongue. If the swallowing reflex were normal, the patient would have swallowed before the applesauce arrived here.

Delayed swallow reflex (2 of 4)

Because of the viscosity of the material it "hangs" for a moment and does not fall down into the entrance of the larynx. Even with a delayed swallow reflex, there is still a second or two to swallow before that happens. The patient will tend to cough less with this consistency than with water.

Blue-stained water (3 of 4)

Here, blue-stained water is flowing into the right pyriform sinus (left of photo at arrow). Movement is rapid (note the blur) due to the low viscosity of water; there is less time to react and swallow than with applesauce, explaining why coughing on water is more common than purée or solid.

No residue (4 of 4)

Still, at the end of several boluses of applesauce and water, stained with blue food coloring, there is no stain or residue inside the entrance of the airway. The delayed swallowing reflex is a liability but without a risk of pneumonia.

Scarring Diverts Swallowed Materials Directly into the Larynx

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Post tonsillectomy (1 of 4)

A young woman struggles to swallow after extensive cauterization of severe bleeding after tonsillectomy elsewhere. The arrows here show the path food and liquid should follow to get into the esophagus (opening indicated by flat oval).

Closer view (2 of 4)

Closer view shows that the epiglottis is tethered to base of tongue at the dotted line. Furthermore, the "ski jump" scar appears to be ready to divert swallowed material directly into the larynx ( arrow) rather than into the pyriform sinus at *.

The "chute" (3 of 4)

A closer view shows even better the "chute" into the larynx.

Abnormal diversion (4 of 4)

While swallowing blue-colored water, arrows indicate the normal path on the left (right of photo) and the abnormal diversion into the larynx on the right (left of photo). The patient manages, but must swallow carefully, especially since the epiglottis cannot invert since it is scarred to the base of tongue as shown in photo 2.

Skull Base Fracture and Vagus Nerve Injury—Note Pharynx Contraction and Impact on Swallowing

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Palate branch of the vagus nerve (1 of 4)

This young woman sustained facial bone and skull base fracture during an auto accident. In this nasopharynx view, note that her right palate (left of photo) elevates fully (long arrow), while the left side only partially (short arrow). The palate branch of the vagus nerve is injured on the left (right of photo).

Pharynx branch of the vagus nerve (2 of 4)

At rest, the pharynx appears flat and symmetrical, but there is a question whether the midline may have migrated to the patient’s right (left of photo). The vagal branch to the pharynx is also injured on the left (right of photo)

Damage to left vagal nerve function (3 of 4)

By eliciting a very high-pitched voice, a pharynx contraction is recruited and now we can see that the pharyngeal wall pulls to the right (horizontal arrow) and the constrictor muscle squeezes inward only on the right (long arrow at left of photo). This confirms good right vagal function (left of photo) and damage on the left (not pictured).

Residue during swallowing test (4 of 4)

After eating a cracker and attempting to wash it away with water, the residue is primarily in the vallecula and left pyriform sinus. Arrows show how the pharynx can squeeze during swallowing in order to clear out the right pyriform sinus (left of photo). With no active muscle on the left (right of photo) to clear out the pyriform sinus, it pools food.

VESS in 6 Still Photos

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Assessing the patient's swallowing (1 of 6)

Step 1 is assessment of the patient's swallowing "equipment." Here we see that the palate elevates symmetrically against the posterior pharyngeal wall.

Observing the pharynx (2 of 6)

The next step is to observe the pharynx squeeze with inferior constrictors bulging to surround the larynx. The vocal cords close fully.

Patient secretions (3 of 6)

Next is the assessment of patient secretions. This hypopharyngeal pooling of saliva (foamy bubbles) predicts that there will be similar pooling of swallowed food materials during the next step of VESS.

Pooling of swallowed pureed food (4 of 6)

As predicted, blue-stained applesauce (purée consistency) pools in the pyriform sinuses. There is no laryngeal soiling (penetration, aspiration).

Swallowing solids (5 of 6)

The next test is the cheese cracker (solid consistency). After swallowing, the residue is seen especially in the vallecula.

Residue after foods (6 of 6)

After several boluses of blue-stained water, a small amount remains in the pyriform sinuses and post-arytenoid area.

VESS (Videoendoscopic Swallow Study) Findings after Radiotherapy

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Narrowed pharyngeal wall (1 of 7)

After radiation and chemotherapy for larynx cancer several years earlier. Note the dry secretions. There is narrowing of the pharyngeal wall (dotted line) due to radiation scarring.

Swallowing applesauce (2 of 7)

After the second bolus of blue-stained applesauce. The propulsive ability ("pitcher of swallowing") is inadequate, leaving a lot of post-swallow residue.

After sipping water (3 of 7)

After three sips of blue-stained water, much of the applesauce has been washed away.

Gravity aiding in swallowing (4 of 7)

Additional water washes nearly all of the residue in the "swallowing crescent" away--mostly by gravity as seen in the next photo.

Lifting larynx (5 of 7)

Each swallow looks like this. The pharynx "bird swallow" mechanism lifts larynx forward so that the swallowing crescent opens down to the cricopharyngeus muscle, indicated by double dotted lines. (PC = post-cricoid.)

A closer look (6 of 7)

At closer range, the cricopharyngeus muscle bulge is seen more clearly, along with the small opening into the esophagus.

Gravity aiding again in swallowing (7 of 7)

Blue-stained water flowing into the esophagus mostly by gravity.

Cervical Osteophytes do not by Themselves Seem a Major Impediment to Swallowing

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Protruding osteophytes (1 of 2)

This 95 year-old man has large cervical osteophytes (bony proliferation due to arthritis). These osteophytes protrude into the pharynx (dotted lines). It would seem they would be a major impediment to swallowing.

Rapid swallowing (2 of 2)

After an initial test swallow, eight boluses of blue applesauce are administered rapidly. The purpose of this is to serve as a “stress test” so that we see his swallowing at its worst…But he has only a small amount of residue, and passes the test. Most individuals with cervical osteophytes are of advanced age. When swallowing is impaired, the explanation is usually more than just the osteophyte.

Aspiration, and Fountain of Returned Aspirate after Coughing

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Salivary pooling (1 of 5)

This young man has a chromosome disorder. He has trouble swallowing but no history of pneumonia. The palate, pharynx, and larynx motor function is normal, but the salivary pooling seen here predicts what follows…

After applesauce (2 of 5)

After several boluses of blue-stained applesauce, there is significant pooling (residue), but nothing down at the level of the vocal cords.

After cheese cracker (3 of 5)

After chewing and swallowing a cheese cracker, a part is lodged in the vallecular.

After water (4 of 5)

During administration of blue-stained water, a large drip is seen falling downwards, directly into the laryngeal vestibule.

Cough expels the water from airway (5 of 5)

A moment later, a cough sprays the aspirated blue-stained water upwards and out of the airway.

Zenker’s Diverticulum Returns Its Contents Upwards to the Throat After Each Swallow

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VESS (1 of 3)

During Videoendoscopic swallow study (VESS), this patient has just swallowed blue applesauce. It has disappeared downwards (arrows) into the upper esophagus but part of it is retained in a Zenker's diverticulum (out of view).

Swallowing Crescent (2 of 3)

Exactly one second later blue applesauce appears in the swallowing crescent as the sac empties a part of its contents upwards.

Applesauce spills into airway (3 of 3)

One second later, even more blue applesauce has emerged. If it were more liquid, it would spill forward to enter the airway. This explains the constant throat clearing and re-swallowing of persons with Zenker's diverticula (caused by antegrade cricopharyngeus dysfunction).

Three Views of the Entrance to the Esophagus from far Away to Close-up

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Swallowing Crescent (1 of 3)

During swallowing, the “the swallowing crescent”—outlined by the dotted line—receives swallowed food or liquid in order to funnel it into the esophagus (not open in this view). The asterisks are reference points to compare all three photos. One does not want any material to enter the laryngeal vestibule (hashed lines).

Closed esophagus (2 of 3)

A closer view. The esophagus is still not open in this view. Compare asterisk with prior and following photo.

Open Esophagus (3 of 3)

At the moment of a dry swallow, the esophagus opens as shown here. Again, the asterisks allow comparison with photos 1 and 2.

Videos:

Videoendoscopic Swallowing Study (VESS)
This video features an example of a 100-year-old patient undergoing VESS.

Videofluoroscopic Swallowing Study (VFSS)

An x-ray-based method of evaluating a person’s swallowing ability. The videofluoroscopic swallowing study (VFSS) is also sometimes called the modified barium swallow, or the “cookie swallow.”

In a radiology suite under fluoroscopy (which creates moving rather than still x-ray images), the patient is asked to swallow barium in thin liquid and paste consistencies, and then in paste on a cookie or cracker. The barium bolus is followed radiographically through the mouth, throat, and into the esophagus. Both lateral and anteriorposterior views are recorded and, depending on the facility, a simple screening sequence of the subsequent movement down the esophagus is also recorded.


Photos:

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (seen as a dark column). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction, before and after myotomy: Series of 2 photos

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Cricopharyngeal dysfunction: before myotomy (1 of 2)

Lateral x-ray of the neck while swallowing barium (the dark material seen here in the throat). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)

After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Videos:

Barium Swallow (Barium Esophagram)
This video presents a clear visual example of a barium swallow, a test that involves having the patient swallow a barium solution while using x-rays to observe the flow of the barium, which can reveal swallowing deficiencies.
Cricopharyngeal Dysfunction: Before and After Cricopharyngeal Myotomy
This video shows x-rays of barium passing through the throat, first with a narrowed area caused by a non-relaxing upper esophageal sphincter (cricopharyngeus muscle), and then after laser division of this muscle. Preoperatively, food and pills were getting stuck at the level of the mid-neck, and the person was eating mostly soft foods. After the myotomy (division of the muscle), the patient could again swallow meat, pizza, pills, etc. without difficulty.