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Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Recurrent Respiratory Papillomatosis (RRP) and Other HPV-Induced Lesions

Posted on December 18, 2015 by Dr. Robert Bastian

A disorder in which wart-like tumors or other lesions grow recurrently within a person’s airway. These growths are caused by the human papillomavirus (HPV), and they may occur anywhere in a person’s airway, such as on the vocal cords (by far the most common site), in the supraglottic larynx, or in the trachea. If these growths are removed, they will almost always grow back, or recur; hence, “recurrent respiratory papillomatosis.”

Symptoms and risks of recurrent respiratory papillomatosis:

RRP can be life-threatening in young children, if not carefully followed and treated, since a child’s airway is relatively narrow and can potentially be obstructed completely by the disease’s proliferative growths; moreover, RRP in children tends to grow and recur more aggressively. In adults, RRP will usually only impair voice function (when the growths occur on the vocal cords), though it can also impair breathing in severe cases. Occasionally, RRP can also progress to cancer, and therefore patients found to be at high risk for this (see below) need to be monitored carefully.

Characteristics of the growths:

The growths usually associated with RRP are wart-like tumors, or papillomas, that protrude conspicuously from the surface on which they grow, often in grape-like clusters. These kinds of papillomas are usually seen in patients who have HPV subtypes 6 or 11, which are both lower-risk subtypes for incurring cancer. There are some HPV patients, however, who manifest their HPV infection with subtler, velvety growths within the airway—“carpet-variant” growths, so to speak. Although these “carpet-variant” growths do not have the wart-like appearance of the papillomas typically associated with RRP, there at least a few key points of similarity:

Both the “carpet-variant” and wart-like growths are lesions that sometimes appear, either independently or together, in patients who have HPV;
Both the “carpet-variant” and wart-like growths are stippled with polka-dot vascular markings, because each “loop” in the “carpet” or each “grape” in the wart-like cluster has its own fibrovascular core, seen as a red dot;
Both the “carpet-variant” and wart-like growths can disrupt voice function;
Both the “carpet-variant” and wart-like growths usually recur if they are removed.

Because of these similarities, we consider these “carpet-variant” growths, even when the sole expression of the infection, to be at least a cousin to RRP, within the family of HPV-induced lesions. Many patients with this “carpet-variant” condition have HPV subtypes such as 16 or 18 that are higher-risk for cancer; such patients need to be monitored with particular care.

Treatment for recurrent respiratory papillomatosis:

The primary treatment for RRP and other HPV-induced lesions is careful, conservative surgical removal of the growths. Because these growths almost always recur, surgery must usually be performed on a repeated basis, as frequently as every few weeks in children, but on average much less often in adults. A common interval between surgeries for adult patients is between every six months and every two years, depending on how quickly the RRP or other HPV-related lesion recurs and impairs the patient’s voice function again. There are also a few medical treatments that have been used in addition to surgery, including, among others, interferon, indole-3-carbinol, intralesional mumps or MMR (measles-mumps-rubella) vaccine, cidofovir, and bevacizumab.

Photos:

Papillomas, HPV subtype 11, before and after removal: Series of 4 photos

Papillomas: HPV Subtype 11 (1 of 4)
Papillomas at posterior vocal cords, with left side (right of image) much larger than right. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 4)
Closer view, under narrow band illumination, which accentuates the vascular pattern.

Papillomas, removed: HPV Subtype 11 (3 of 4)
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.

Papillomas, HPV subtype 6, before and after removal: Series of 4 photos

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.

Papillomas: HPV Subtype 6 (2 of 4)
Same lesion, under narrow band illumination.

Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.

Papillomas, removed: HPV Subtype 6 (4 of 4)
Same view, under narrow band illumination.

Papillomas, HPV subtype 11: Series of 3 photos

Papillomas: HPV Subtype 11 (1 of 3)
Panoramic view, standard light, shows papillomas on the aryepiglottic cord, false cords, anterior face of arytenoid, and at anterior commissure. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 3)
Closer view, standard light, shows more clearly the papillomas on the anterior face of the right arytenoid and at the anterior commissure.

Papillomas: HPV Subtype 11 (3 of 3)
Still closer view, to see more clearly the anterior commissure papilloma.

HPV lesions: Series of 2 photos

Lesions of HPV Subtype ? (1 of 2)
Under standard light, faint stippled vascularity is seen, along with a general mild inflammatory response (pinkness). Patients like this are often misdiagnosed with acid reflux.

Lesions of HPV Subtype ? (2 of 2)
Same patient, narrow band light. Now seen is the stippled, HPV-effect kind of vascularity of “carpet-variant” lesions.

Lesions and papillomas of HPV, before and after removal and adjuvant injection: Series of 8 photos

Lesions and papillomas of HPV subtype ? (1 of 8)
At initial diagnosis, as yet untyped for HPV. Multi-focal lesions on both vocal cords.

Lesions and papillomas of HPV subtype ? (2 of 8)
Narrow-band illumination and a different viewing angle better reveal the more subtle lesion on the upper surface of the right cord (dotted circle).

Lesions and papillomas of HPV subtype ? (3 of 8)
Strobe light, open phase of vibration, showing mismatch.

Lesions and papillomas of HPV subtype ?, 1 week after removal (4 of 8)
One week after removal of papillomas, voice is dramatically restored. Strobe light, open phase of vibration. Compare with photo 3.

Lesions and papillomas of HPV subtype ?, 1 week after removal (5 of 8)
Strobe illumination, closed phase. Even in falsetto, oscillatory ability is preserved due to the precise and superficial removal of the papillomas.

Lesions and papillomas of HPV subtype ?, 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.

Lesions and papillomas of HPV subtype ?, 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.

Lesions and papillomas of HPV subtype ?, 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.

Papillomas, HPV subtype 55, going into remission: Series of 4 photos

Papillomas: HPV Subtype 55 (1 of 4)
Papillomas of the vocal cords, in a patient with HPV subtype 55, which is intermediate-risk for progressing to cancer.

Papillomas: HPV Subtype 55 (2 of 4)
Same exam, with narrow-band lighting, which accentuates the vascular pattern of the papillomas.

Papillomas, in remission: HPV Subtype 55 (3 of 4)
Same patient, years later, in remission, and with normal voice. No sign of papillomas here or anytime during the prior three and a half years, after meticulous removal and Cidofovir treatment.

Papillomas, in remission: HPV Subtype 55 (4 of 4)
Same exam as photo 3, with narrow-band lighting. The vascular dots on the vocal cords are not HPV-related.

Papillomas, HPV subtype 11: Series of 2 photos

Papillomas: HPV Subtype 11 (1 of 2)
Vocal cords, narrow band light, showing papillomas on the upper surface of the anterior vocal cords. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 2)
Tracheal view, standard light, showing scattered papillomas (arrows). The carina is in the distance.

Papillomas, HPV subtype 31, going into remission: Series of 4 photos

Papillomas: HPV Subtype 31 (1 of 4)
Standard light, showing lesions on the vocal cords, in particular the stippled vascular pattern we call "HPV effect." The patient's voice was nearly gone, with numerous syllable drop-outs and a very effortful quality. Compare with photo 3.

Papillomas: HPV Subtype 31 (2 of 4)
Closer view, using narrow-band light to accentuate the vascular pattern of "HPV effect." Biopsy and additional testing of these lesions showed squamous papilloma with moderate dysplasia, and HPV subtype 31 was confirmed, which is high risk for eventually causing cancer. After the patient underwent several injections of cidofovir, the lesions persisted but seemed to become more indolent. On compassionate grounds, this fairly young person was then prescribed celecoxib for six months.

Papillomas, in remission: HPV Subtype 31 (3 of 4)
Three years after photos 1 and 2, standard light view. Within two months of the start of celecoxib, voice improved very noticeably, and the "HPV effect" vascularity resolved. Still, it is unknown what roles in this recovery were played by the patient's immune system, the cidofovir, and the celecoxib, respectively.

Papillomas, in remission: HPV Subtype 31 (4 of 4)
Closer view than photo 3, under narrow-band light.

Papillomas, HPV: Series of 2 photos

Papillomas: HPV Subtype ? (1 of 2)
Papillomas involving both the true and false vocal cords.

Papillomas: HPV Subtype ? (2 of 2)
At higher magnification, the stippled vascular markings become more evident.

Pushing past red herrings to find the real issue: Series of 3 photos

Obvious lesion not important (1 of 3)
Several months after removal of exuberant papillomas, voice remains quite good, but is becoming a little deeper. The obvious lesion here is not important; the subtle one is the key.

Granuloma (2 of 3)
Narrow band light reveals the spherical lesion to be a granuloma, not papilloma (which would have stippled vascular markings).

Carpet-varient papilloma (3 of 3)
At closer range, still under narrow band light, carpet-variant papilloma can be seen on the posterior right vocal cord (left of photo). This is the important finding.

Papillomas, HPV subtype 18 or 45: Series of 2 photos

Papillomas: HPV Subtype 18 or 45 (1 of 2)
Papilloma growths on the right vocal cord (left of image), standard light. This patient's papillomatosis is caused by HPV, narrowed down to either subtype 18 or 45.

Papillomas: HPV Subtype 18 or 45 (2 of 2)
Slightly magnified view of the same papilloma growths under narrow-band illumination, which accentuates the vascular pattern.

Lesions of HPV subtype 16: Series of 3 photos

Lesions of HPV Subtype 16 (1 of 3)
Recurring inflammatory and leukoplakic lesions caused by HPV subtype 16. A left vocal cord cancer (right of image) was removed several years earlier, and the patient developed a right vocal cord cancer almost a year later.

Lesions of HPV Subtype 16 (2 of 3)
Slightly magnified view, focusing on the anterior (frontward) ends of the vocal cords. The cords' stippled vascularity, which often accompanies HPV infection, is more apparent here.

Lesions of HPV Subtype 16 (3 of 3)
A similar view to image two, but with narrow-band illumination, which accentuates the vascular pattern. Biopsy/removal of these lesions revealed high-grade dysplasia; re-biopsy almost a year after this examination returned a diagnosis of cancer.

Cancer, HPV Subtype 16, before and after radiation: Series of 5 photos

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: HPV Subtype 16 (2 of 5)
Closer view.

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.

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.

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.

Papillomas, HPV subtype 45: Series of 2 photos

Papillomas: HPV Subtype 45 (1 of 2)
Papillomas in the supraglottis, left of image. The pink, velvety area of papillomas is outlined by small arrows.

Papillomas: HPV Subtype 45 (2 of 2)
Closer view of the vocal cords, showing leukoplakia. This is presumably a second expression of the HPV infection, though the typical dotted or pointed vascular marks of HPV are not seen in the area of the leukoplakia.

Mid-tracheal papilloma, treated by thulium laser: Series of 5 photos

Mid-tracheal papilloma, being treated by thulium laser (1 of 5)
The papilloma is seen attached to the posterior tracheal wall, at the midpoint of the trachea. Note the areas of scarring from prior laser procedures. The dots seen indicate reference points for photo 5.

Mid-tracheal papilloma, being treated by thulium laser (2 of 5)
Using the channel scope, a blue glass fiber is extended from the tip of the scope.

Mid-tracheal papilloma, being treated by thulium laser (3 of 5)
In a closer view, the papilloma has been mostly cauterized using near-contact (not touching) mode.

Mid-tracheal papilloma, being treated by thulium laser (4 of 5)
The papilloma is then penetrated multiple times to deliver laser energy to its base. Some of the papilloma is pulled off by attachment to the fiber, and the remainder will slough off and be swept upwards by the mucociliary blanket (thin layer of mucus being swept upward) within the trachea.

Months after treatment: no papilloma (5 of 5)
Durable resolution of papilloma, many months afterwards. Compare with photo 1.

Subtle papillomas, HPV subtype 6: Series of 3 photos

Subtle papillomas, HPV subtype 6 (1 of 3)
After achieving a normal voice through several procedures, the patient came in for reexamination due to the return of mild huskiness. This distant panoramic view with standard illumination does not reveal any obvious papillomas.

Subtle papillomas, HPV subtype 6 (2 of 3)
At close range, using narrow band illumination, a subtle but definite HPV effect is seen. Notice the stippled vascular markings and the faintly increased pinkness at the margins of the cords, indicated by dotted lines.

Subtle papillomas, HPV subtype 6 (3 of 3)
With the vocal cords now at the pre-phonatory instant, these low-profile HPV-related papillomas are again seen, indicated by dotted lines.

HPV vascular effect: Series of 3 photos

Two papillomas (1 of 3)
Approximately one month after removal of papillomas and Avastin injection in a man who has battled aggressively-recurring disease caused by HPV, type 6. In this view using narrow band light, only two small papillomas are visible.

Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.

HPV vascular effect (3 of 3)
HPV vascular effect is seen even more clearly.

Laryngeal papillomas rarely can be found by ... accident: Series of 4 photos

Papilloma finding (1 of 4)
This young man had a tonsil problem and normal voice but during the initial head and neck examination was found to have a papilloma in his larynx. Rapid recurrence and spread triggered referral. Note stippled vascularity on masses along the edges of the false vocal cords.

Narrow band light (2 of 4)
Narrow band light makes the papillomas much more evident.

Closed phase (3 of 4)
Under strobe light, closed phase of vibration, the true cords are seen to be uninvolved, and this explains his normal voice.

Open phase (4 of 4)
Open phase of vibration, strobe light. The plan is definitive removal and HPV subtyping.

Winning papilloma battles, but not winning the war....yet: Series of 8 photos

Left vocal cord lesion (1 of 8)
Middle aged woman with a 6-month history of hoarseness. Note the left vocal cord lesion (right of photo at arrow).

Narrow band light (2 of 8)
At closer range under narrow band light, the stippled vascular pattern suggests that this is HPV-related papilloma. Very tiny secondary lesions may be present at the arrow and ?

One week after removal (3 of 8)
A week after removal (and proof of HPV subtype 6), the left cord (right of photo) shows expected pinkness. The tiny lesion under the right cord (left of photo) “escaped” and appears larger but is still not a verifiable papilloma, nor is the tiny lesion on the upper surface of the right cord (left of photo) at the ?

2 months after removal (4 of 8)
Now 2 months after surgical removal of the original left cord lesion, that cord is healed and without evidence of papilloma. Voice is excellent—can pass for normal—but the tiny lesions previously seen are now verifiably flat papillomas (see stippled vascularity at arrows).

7 months after removal (5 of 8)
Now 7 months after original surgery, voice remains “almost” normal to the patient. Cord margins match well with voicing. Irregular margins are primarily due to overlying mucus.

Papilloma and mucus (6 of 8)
With abduction of the cords for breathing, a papilloma is seen below the margin of the right cord (left of photo at large arrow); the small arrows outline a peculiar “elevated” area that looks to be more than mucus the mucus seen at 'X'.

Stippled vascularity (7 of 8)
At closer range, under narrow band light, the stippled vascular marks further define the papilloma. Note normalized vasculature on the left cord (right of view) where the original papilloma was found. The “battle” of the left cord (right of photo) may have been won…

HPV disease (8 of 8)
Still under narrow band light, stippled vascularity in the area of the arrows suggests that this elevated area also represents HPV disease.

What "cured" this case of RRP? Surgery? Cidofovir? The patient's immune system? All three?: Series of 8 photos

Papilloma (1 of 8)
Papilloma on right vocal cord (left of photo), proven by biopsy elsewhere. The disease has both a projecting component along with 'carpet-variant' component seen only via stippled vascular marks (within dashed line).

Stippling (2 of 8)
Closer view under strobe light; stippling is seen more clearly. Compare the stippling with the linear capillaries of the opposite cord.

One week after surgical removal (3 of 8)
One week after removal and sub typing (HPV 6) and cidofovir injection. Under narrow band light there is residual bruising but no significant stippling.

Cidofovir injection (4 of 8)
At final office-based cidofovir injection. Blood from the injection is seen, but still no stippling.

Six months after surgical removal (5 of 8)
Six months after removal, papillomas have recurred at the margin of the vocal cord, but not on its upper surface where linear capillaries have replaced stippling.

One week after second removal (6 of 8)
A week after second removal of papillomas and cidofovir injection, with expected inflammation, but no visible remaining stippled vascularity.

4 months later, healed (7 of 8)
4 months later, the vocal cord has long since healed and narrow band light is used to accentuate capillaries. No HPV effect (stippling) is seen.

3 years later, no sign of papilloma (8 of 8)
3 years later, there is still no sign of papilloma or stippled vascularity (HPV effect).

RRP Cure? Or just long term remission?: Series of 4 photos

Chronic hoarseness (1 of 4)
Chronic hoarseness, due to these papillomas, subsequently proven to be caused by subtype 6. Note HPV-effect vascularity.

4 months later (2 of 4)
A second surgery, 5 cidofovir injections (3 in office), and 4 months later, neither papilloma nor HPV vascular effect are seen here, under narrow band light.

8 months from start of treatment (3 of 4)
Now 8 months from the start of treatment, and 5 months since the final (office) cidofovir injection, there remains no evidence of abnormality. This view is under standard light.

Narrow band lighting (4 of 4)
An even closer view under narrow band light still shows no sign of HPV effect or papilloma. Voice is normal and vibratory flexibility is maintained when examined under strobe light.

Polyps need a close look: here's one reason why: Series of 4 photos

"Polyps" diagnosis (1 of 4)
This patient is representative of persons initially diagnosed with "polyps," based upon a view like this one.

Papillomas (2 of 4)
Now we can see that these lesions are papillomas by the powerful visual criterion of vascular stippling aka "HPV vascular effect." Another clue of incorrect diagnosis, even with a distant view, would be the patient's non-match with the vocal overdoer syndrome.

Vascular stippling (3 of 4)
Narrow band light at the same magnification accentuates the vascular stippling. Typical papillomas indicated by arrows, and faint lines online areas of "carpet variant" papillomas.

Prephonatory instant (4 of 4)
Prephonatory instant shows additionally that the right vocal cord lesion (left of photo) is in the wrong location for vibratory injury.

Long-term remission or even "cure" of RRP/ laryngeal papilloma: Series of 6 photos

Chronic hoarseness (1 of 6)
In this distant view, the nature of the abnormality of the right vocal cord (left of photo) is not well seen, and the lesion of the left posterior cord (right of photo) is subtle.

Narrow band light (2 of 6)
Under narrow band light, the two discrete lesions are better identified as being papillomas due to the punctate (dotted) vascular markings.

Higher magnification (3 of 6)
Again under standard light but at higher magnification.

Higher magnification, narrow band lighting (4 of 6)
Back to narrow band light, to more carefully scrutinize the anterior right vocal cord lesion (left of photo).

Post-operation (5 of 6)
18 months after surgical removal and cidofovir injection, voice is excellent and there is no sign of recurrent papilloma.

Post-operation, narrow band lighting (6 of 6)
Under narrow band light, no stippled vascularity is seen. The question is: is remission due to surgery, cidofovir, or the patient's immune system?

Injected local anesthetic causes blanching: Series of 3 photos

Infiltrating anesthetic (1 of 3)
A 27-gauge needle tip is poised to infiltrate local anesthetic lidocaine with epinephrine into the papillomas (within dotted line) located just below the anterior commissure. In a moment, the needle will enter the papillomas at the "X".

Blanching (2 of 3)
The needle is buried and the tissue is blanching due to hydrostatic pressure of the injected fluid. The green dot is for reference with photo 3.

Subglottis being injected (3 of 3)
Farther below the vocal cords, the anterior subglottis is seen here being injected. The green dot is for reference with photo 2. The shank of the needle guide looks like a "Doctor Octopus" arm!

Local rather than topical anesthesia can permit fairly major tracheal surgery: Series of 4 photos

Obstructive papillomas (1 of 4)
This middle aged man has had lifelong RRP due to HPV 11. Primary focus of his recurrences for many years has been the trachea. Prior operative removals under general anesthesia have been challenging and recent work has used the thulium laser in an office setting. The papillomas seen here explain his mild pre-procedure stridor. His tracheal lumen should be approximately the size of the dotted circle.

Local injections (2 of 4)
A needle catheter passed through the channel of the scope is embedded at arrow, and is injecting 1% lidocaine with epinephrine (see blanched area). Numerous areas are similarly injected.

Removal of papilloma (3 of 4)
Here a large chunk of papilloma (stuck to the laser fiber at arrow) is being pulled away.

Improved breathing with papilloma removal (4 of 4)
An additional chunk is being detached. The patient’s breathing at the conclusion of this procedure is much improved. The tracheal lumen will be even larger when a lot of remaining coagulated papillomas slough away.

Videos:

https://youtu.be/1zQ9jy6JVxo

Papillomas of the Larynx and Trachea (https://youtu.be/1zQ9jy6JVxo)

Papillomas of the Larynx and Trachea
This video shows wart-like growths in the voicebox and windpipe (larynx and trachea) caused by chronic infection with the human papillomavirus (HPV).

https://vimeo.com/77169624

Pulsed-KTP Laser Coagulation of Vocal Cord Papillomas (RRP) (https://vimeo.com/77169624)

Pulsed-KTP Laser Coagulation of Vocal Cord Papillomas
See a video demonstration of laser coagulation of vocal cord papillomas.

Chondroma

Posted on December 31, 2014 by Dr. Robert Bastian

A benign growth composed of cartilage cells.

Photos:

Chondroma of thyroid cartilage: Series of 4 photos

Chondroma of thyroid cartilage (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 (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.

Chondroma of thyroid cartilage (3 of 4)

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

Amyloidosis

Posted on June 20, 2013 by Dr. Robert Bastian

A condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells. In some cases, the cause of amyloidosis is a systemic disorder in which the body over-produces proteins–for example, multiple myeloma, a blood disease; in this scenario, the amyloid deposits can be dispersed widely across the body. In other cases, the amyloid deposits do not seem to reflect systemic disease and can be more organ-specific.

Amyloidosis in the larynx:

In laryngeal amyloidosis, the deposits seem to be localized either just to the larynx, or to the larynx and pharynx. One sees what looks like yellowish candle wax within the tissues. The amyloid deposits are quite firm, and when biopsied, there is little bleeding.

Treatment for laryngeal amyloidosis:

Because of their infiltrative nature, amyloid deposits typically cannot all be dissected out of the larynx; instead, then, an operating physician will aim to debulk the deposits in areas where they impair breathing or the voice. That is, when deposits are widespread in the larynx, there does not seem to be any point in removing them except in locations where removal will improve function. Often, repeated procedures are required over many years’ time, though occasionally the condition seems to stop progressing.

Photos:

Amyloidosis, before and after debulking: Series of 4 photos

Amyloidosis, before debulking (1 of 4)

Panoramic view. Submucosal amyloid deposits in pharyngeal walls and epiglottis, with examples at arrows.

Amyloidosis, before debulking (2 of 4)

View of anterior subglottis shows diffuse infiltration of yellowish, submucosal amyloid.

Amyloidosis, before debulking (3 of 4)

Phonation under strobe light shows deposit at anterior commissure tethering upper surface of left vocal cord, and resultant vibratory asymmetry.

Amyloidosis, after debulking (4 of 4)

Some months later, after laser debulking at short arrow, showing improvement of vibratory closure after tethering reduced. Note increase of nearby supraglottic amyloid deposit does not need to be addressed because it has no functional consequence to the patient, who has other asymptomatic deposits in subglottis, epiglottis, and nasopharynx.

Amyloidosis: Series of 1 photo

Amyloidosis, before and after debulking: Series of 8 photos

Amyloidosis, before debulking (1 of 8)

Panoramic view of a large spherical mass of amyloid material bulging submucosally (contour at dotted line) in the false and aryepiglottic cords. The patient has only a harsh stage whisper, and glottic voice only with inspiratory (inhaling) phonation. The posterior vocal cord and ventricle of the opposite side (left of photo) are visible, but the amyloid mass obscures all but a few millimeters of the posterior cord on its side.

Amyloidosis, before debulking (2 of 8)

Closer view.

Amyloidosis, before debulking (3 of 8)

View yet further down, showing the upper trachea (top-center of photo), the posterior end of one of the vocal cords (left of photo), and the edge of the amyloid mass (bottom-right of photo, again marked by a dotted line). The mass is again obscuring a view of the vocal cord on its side; in fact, it is pressing the cord downward, which affects the voice.

mass overlies most of both vocal cords — Amyloidosis, before debulking (4 of 8)

Phonation, while attempting to see the vocal cords beyond the large overhanging mass. The vocal cords are each marked with an F, one of the posterior ventricles with a V, and the amyloid mass with an A. This mass actually overlies most of both vocal cords and presses them both downward.

Amyloidosis, after debulking (6 of 8)

Looking into the deepest recess of the dissection. The parallel lines indicate the upper border of the thyroid cartilage.

Complete healing (8 of 8)

Many months after debulking, and with complete healing, the voice can pass for normal, and the laryngeal vestibule is no longer filled with the enormous bulk of amyloid. The nubbin at anterior false cord would only need removal if it became large enough to interfere with voice.

Proteinaceous deposits of primary laryngeal amyloidosis can occur anywhere and “everywhere” in the larynx: Series of 4 photos

Airway Passage (1 of 4)

This middle-aged woman has experienced gradual deterioration of voice across several years. Note the narrowed airway and protruding lesions.

Submucosal Masses (2 of 4)

In a closer view, one gets the sense of firm submucosal masses (most prominent deposits circled, at arrows). Note the yellowish cast as well. Vocal cord margins are marked with dotted lines.

Diffuse Subglottic Infiltration (4 of 4)

Just below the vocal cords, diffuse subglottic infiltration is also seen, with the most prominent deposit posteriorly at the arrow.

yellowish amyloid deposits — Amyloid Deposits (3 of 4)

At closer range, the yellowish cast typical of amyloid deposits is seen better.

Videos:

Amyloidosis
This video gives an example of amyloidosis, which is a condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells.

Verrucous Carcinoma

Posted on March 4, 2013 by Dr. Robert Bastian

Verrucous carcinoma is a variant of squamous cell carcinoma (SCCA). In the head and neck, this uncommon subtype of SCCA is seen most often in the oral cavity or on the vocal cords. Visually, it tends to have an exophytic (outward-growing) and wartlike, irregular surface. This variant of SCCA is typically less aggressive than other squamous cell carcinomas. Local recurrence tends to be the issue more than distant metastasis. Surgery tends to be the most effective treatment, though of course every patient’s circumstance is individualized and considered in the light of three treatment options: surgery, radiation therapy, and chemotherapy.

Photos:

Verrucous carcinoma, before and after laser treatment: Series of 5 photos

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 (2 of 5)
During voicing.

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.

Verrucous carcinoma, several weeks after laser treatment (4 of 5)
Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.

Verrucous carcinoma, several weeks after laser treatment (5 of 5)
During voicing. Arytenoid moves, but much of membranous vocal cord has been ablated as intended.

Sarcoma

Posted on August 1, 2012 by Dr. Robert Bastian

A malignant tumor that originates in mesenchymal tissue. Mesenchymal tissue comprises muscle, bone, fat, connective tissue, blood vessels, and cartilage. If, instead, a malignancy originates in lining or covering tissues—which includes skin, bronchial tubes, the lining of the mouth, throat, and gastrointestinal tract, and breast and salivary gland ducts—then that tumor is called a carcinoma.

Carcinomas are far more common than sarcomas, and sarcomas involving the larynx are rare, with chondrosarcoma (“chondro-” refers to cartilage origin) heading the list. The clinicians at our laryngology practice have seen hundreds of carcinomas in their career, but probably no more than 20 sarcomas.

Photos:

Sarcoma: Series of 2 photos

Sarcoma (1 of 2)
Sarcoma of larynx. The tumor nearly fills the glottis.

Sarcoma (2 of 2)
Closer view, showing the posterior commissure airway.

Human Papillomavirus (HPV)

Posted on June 28, 2012 by Dr. Robert Bastian

A DNA virus that may cause cutaneous warts, genital warts, or the clinical condition recurrent respiratory papillomatosis (RRP) in susceptible individuals. Human papillomavirus (HPV) may occur in as many as 150 or more subtypes. The most common subtypes seen in patients with RRP are HPV 6 and 11. Other less common subtypes that can induce papillomas or other growths within the larynx include HPV 16, 18, 31, 44, 45, 55, 69, 84 & 11, 33 & 45 and some of these subtypes are associated with a higher risk of cancer formation. See the photo series below, displaying all of the subtypes mentioned above.

Common Questions About HPV

Q: What is the relationship between the terms RRP, HPV, and Papilloma?

A: The underlying disorder is HPV (human papilloma virus) infection of the airway, especially the larynx. The virus “sets up house” chronically inside airway and stimulates a kind of proliferation called papillomas, or papillomatosis. Because these lesions tend to recur after surgical removal, the clinical syndrome has become referred to as recurrent respiratory papillomatosis (RRP).

Q: HPV apparently has different subtypes. What can you tell me about them?

A: Human papilloma virus infection can consist of as many as 150 different subtypes. Some are related to skin infection (causing warts). Some are more common in genital or respiratory sites. Genital lesions are typically called condylomata, or genital warts. In the airway, the lesions are typically called papillomas. Commonest subtypes in the airway are types 6 and 11. These two subtypes comprise the vast majority of our patients at BVI. We have patients who have also tested positive for types 16, 18, 45, 55, and a few others.

Q: I have a low-risk subtype of HPV. Can you explain what this means?

A: The human papilloma virus (HPV) comes in 150 or more subtypes. Think of it like the many models of automobiles that all fall under the designation “Ford.” Subtypes found most often in the respiratory and genital tracts are 6 and 11. HPV infection is associated with some degree of risk of stimulating, or converting to, a carcinoma. Hence the higher risk of cervical cancer in women with HPV infection. Some subtypes are considered to have a low risk of viral carcinogenesis; others have a high risk. At BVI, the majority of our many adult patients have 6 or 11, both of which are low-risk subtypes. We also have one or two who have both 6 and 11. Then we have a handful of patients with intermediate or high risk for cancer. A few of these high-risk subtypes have in fact caused cancers in our population of ~150 adult patients with RRP. Thankfully, all have responded well to treatment and none to my memory have died from their cancer.

Photos:

Subtype 6

More common subtype seen in the airway. HPV 6 is associated with a lesser risk of cancer formation, as is HPV 11.

Papillomas, HPV subtype 6, before and after removal: Series of 4 photos

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.

Papillomas: HPV Subtype 6 (2 of 4)
Same lesion, under narrow band illumination.

Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.

Papillomas, removed: HPV Subtype 6 (4 of 4)
Same view, under narrow band illumination.

Subtle papillomas, HPV subtype 6: Series of 3 photos

Subtle papillomas, HPV subtype 6 (3 of 3)
With the vocal cords now at the pre-phonatory instant, these low-profile HPV-related papillomas are again seen, indicated by dotted lines.

Subtle papillomas and the importance of a motivated examination: Series of 4 photos

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.

HPV vascular effect: Series of 3 photos

Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.

HPV vascular effect (3 of 3)
HPV vascular effect is seen even more clearly.

Type 6 HPV Papillomas firmer than most: Series of 4 photos

Stippled vascularity not seen (1 of 4)
Diffuse involvement of true and false cords with papilloma caused by HPV 6. After hundreds of procedures from childhood through early adulthood, the stippled vascularity is not extremely evident in this standard-light view.

HPV vascular effect (2 of 4)
At closer range, still under standard light, the characteristic vascularity—what we term “HPV vascular effect”—is only beginning to be evident (arrows).

Vascularity clearly seen (3 of 4)
At still closer range, and now under narrow-band light, stippled vascularity is clearly seen (arrows).

Under narrow-band light (4 of 4)
Even closer view still under narrow-band light: the stippled vascularity is now unmistakable.

HPV 6: Going, going, gone?: Series of 7 photos

“Curative mode” plan (1 of 7)
Known HPV 6-induced laryngeal papillomas, with resulting gross hoarseness. The plan is “curative mode” defined as 3 or more successive, surgical cleanouts with adjuvant injection to see if the disease can be put into remission or at the least “tamed” to less rapid recurrence.

Closer view (2 of 7)
At closer range. Still, the full extent of disease becomes more obvious at the anterior right vocal cord (left of photo at arrow) in the next photo, when viewed under narrow band illumination (NBI).

Narrow-band illumination (3 of 7)
Now under NBI, the right anterior vocal cord (left of photo) involvement is seen clearly.

Post surgery (4 of 7)
A few days after surgical removal using the usual “basement membrane peel” technique of removal and in this case cidofovir injection. Voice is already dramatically improved, the right cord (left of photo) retains vibratory ability, and the grey wound base is seen clearly.

Towards “management mode” (5 of 6)
Voice had been “normal” until recent weeks, and so the patient therefore waited longer than intended for followup surgery, to the point that we are drifting out of “curative mode” and over into “management mode.” Here, under standard light, the disease is not that obvious.

Same view under NBI (6 of 7)
Under NBI at closer range, the carpet of HPV upper surface and one actual papilloma are more evident, but it is still not quite clear why the patient says voice has been getting slightly hoarse.

Stippled vascularity seen (7 of 7)
At closer range, faint HPV-induced vascular stippling is seen along the margin of the right vocal cord (left of photo) within the dotted line, and this explains his subtle and increasing hoarseness. Another surgical cleanout with adjuvant medication is scheduled.

Subtype 11

One of the more common subtypes seen in the airway. HPV 11 is associated with a lesser risk of cancer formation, as well as HPV 6.

Papillomas, HPV subtype 11, before and after removal: Series of 4 photos

Papillomas: HPV Subtype 11 (1 of 4)
Papillomas at posterior vocal cords, with left side (right of image) much larger than right. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 4)
Closer view, under narrow band illumination, which accentuates the vascular pattern.

Papillomas, removed: HPV Subtype 11 (3 of 4)
Two weeks after microsurgical removal, cidofovir injection, and return of normal voice.

Papillomas, HPV subtype 11: Series of 3 photos

Papillomas: HPV Subtype 11 (2 of 3)
Closer view, standard light, shows more clearly the papillomas on the anterior face of the right arytenoid and at the anterior commissure.

Papillomas: HPV Subtype 11 (3 of 3)
Still closer view, to see more clearly the anterior commissure papilloma.

Papillomas, HPV subtype 11: Series of 2 photos

Papillomas: HPV Subtype 11 (1 of 2)
Vocal cords, narrow band light, showing papillomas on the upper surface of the anterior vocal cords. This patient has HPV subtype 11.

Papillomas: HPV Subtype 11 (2 of 2)
Tracheal view, standard light, showing scattered papillomas (arrows). The carina is in the distance.

Subtype 16

Less common in the airway than the more common subtypes 6 and 11. HPV 16 is associated with a higher risk of cancer formation, along with HPV subtypes 18, 31, 45, 55, and others.

Lesions of HPV subtype 16: Series of 3 photos

Cancer, HPV Subtype 16, before and after radiation: Series of 5 photos

Cancer: HPV Subtype 16 (2 of 5)
Closer view.

Subtype 18

This is less common in the airway than the more common subtypes 6 and 11. HPV 18 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 31, 45, 55, and others.

HPV 18-high risk subtype: Series of 4 photos

Papillomas seen (1 of 4)
Middle-aged man with chronic hoarseness and the lesions seen here, diagnosed by the pathologist as papillomas.

Stippled vascularity (2 of 4)
Closer view. Stippled vascular markings consistent with HPV effect are seen more clearly here.

Soon after microlaryngoscopic removal, and in preparation for followup cidofovir injection.

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Needle (arrow) and blanching and swelling of the left cord as cidofovir is injected. The same technique can be used for Avastin.

Subtype 31

This is less common in the airway than the more common subtypes 6 and 11. HPV 31 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 18, 45, 55, and others.

Papillomas, HPV subtype 31, going into remission: Series of 4 photos

Papillomas, in remission: HPV Subtype 31 (4 of 4)
Closer view than photo 3, under narrow-band light.

HPV 31 as a cause of "chronic laryngitis": Series of 4 photos

Hazy leukoplakia, HPV suspected (1 of 4)
This 20-something nonsmoker without reflux symptoms is chronically hoarse. HPV infection is suspected for the following reason: While hazy leukoplakia can be occasionally seen as a result of excessive voice use, it would be most unusual to this degree, and this far lateral to the vocal cord margin. Biopsy shows only chronic inflammation, and HPV testing is positive for subtype 31.

Leukoplakia remains (2 of 4)
Several months later, the inflammatory reaction with leukoplakia remains.

Leukoplakia demarcated (3 of 4)
Narrow band illumination here makes the leukoplakia patches more demarcated.

HPV effect confirmed (4 of 4)
Within the circle, one can see faint HPV-effect on vasculature (stippling).

HPV 31--> cancer --> cure: Series of 4 photos

Carcinoma in situ (1 of 4)
This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.

HPV subtype 31 (2 of 4)
Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.

Excisions (3 of 4)
After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.

Seven years later (4 of 4)
Seven years later, at an annual visit, there are no stippled or other abnormal vascular marks. Voice has been very acceptable to the patient, if occasionally faintly husky.

Subtype 44

HPV 44: Series of 6 photos

Voiceless 50-year-old man (1 of 6)
This 50-year-old man is virtually aphonic. The vocal cord abnormality is already visible in this distant view.

Vascular stippling (2 of 6)
At closer range and under standard light, the vascular stippling is becoming more visible. The two small 'X's are for reference with Photo 3.

Narrow band light, vascularity (3 of 6)
At even closer range under narrow band light, the vascularity is even more evident. The two small 'X's are for reference with Photo 2.

4 months later, recurrent papillomas (4 of 6)
This man had marked improvement of voice after surgery 4 months earlier but within weeks, voice began to deteriorate due to regrowth of his papillomas.

Open position, narrow band light (5 of 6)
Still in open (breathing) position but now under narrow band light. The stippled vascular markings typical of HPV effect are seen more clearly.

Closing for voicing (6 of 6)
As the cords come into approximation for voicing, still under narrow band light, the recurrent lesions are again seen.

Subtype 45

This subtype is less common in the airway than the more common subtypes 6 and 11. HPV 45 is associated with a higher risk of cancer formation, along with HPV subtypes 16, 18, 31, 55, and others.

Papillomas, HPV subtype 45: Series of 2 photos

Papillomas: HPV Subtype 45 (1 of 2)
Papillomas in the supraglottis, left of image. The pink, velvety area of papillomas is outlined by small arrows.

HPV 45 that caused cancer: Series of 7 photos

HPV type 45 detected (1 of 7)
Panoramic view shows marked enlargement from tumor of false cords. Biopsy shows squamous cell and cancer HPV type 45 is also detected as the likely cause.

Closer view of HPV effect (2 of 7)
Closer view of the true vocal cords showing HPV effect of vascular stippling.

Narrow band illunination (3 of 7)
Narrow band illumination accentuates HPV vascular effect.

Post radiotherapy, glottic web seen (4 of 7)
After radiotherapy with complete response. A glottic web is now seen as a radiation side effect/complication.

Post-radiation web (5 of 7)
Closer view of post-radiation web.

Post-microlaryngoscopy, release of glottic web (6 of 7)
After microlaryngoscopy and release of glottic web. Tumor is gone.

HPV effect no longer seen (7 of 7)
Closer view of final result; patient has very good voice. Note that the HPV-related stippled vascularity is no longer seen.

Subtypes 33 & 45

HPV and Cancer: Types 33 and 45: Series of 5 photos

Hoarse voice (1 of 5)
Chronic hoarseness in a younger woman, diagnosed elsewhere with “nodules.”

Narrow band light (2 of 5)
At closer range, under narrow band light. Note the two distinct vascular patterns: a finer, stippled one of anterior 1/3 and a more coarse and aberrant one on the mid and posterior fold. The pathology report shows invasive carcinoma-in-situ, which was removed using the CO2 laser.

Post excision (3 of 5)
One week after excision of the lesion.

Healed (4 of 5)
After healing, the right fold normalizes remarkably and the patient’s voice sounds normal to her and to the clinician.

"Cured" (5 of 5)
Two years later, laser excision alone (no doubt along with the patient’s immune system) has produced a durable remission/ “cure.”

Subtype 55

This subtype is less common in the airway than the more common subtypes 6 and 11. HPV 55 is associated with an intermediate degree of risk of cancer formation, as compared to other subtypes of HPV.

Papillomas, HPV subtype 55, going into remission: Series of 4 photos

Papillomas: HPV Subtype 55 (1 of 4)
Papillomas of the vocal cords, in a patient with HPV subtype 55, which is intermediate-risk for progressing to cancer.

Papillomas: HPV Subtype 55 (2 of 4)
Same exam, with narrow-band lighting, which accentuates the vascular pattern of the papillomas.

Papillomas, in remission: HPV Subtype 55 (4 of 4)
Same exam as photo 3, with narrow-band lighting. The vascular dots on the vocal cords are not HPV-related.

Subtype 69

HPV Subtype 69 (High-intermediate risk): Series of 2 photos

Standard lighting (1 of 2)
Here, right vocal cord (left of photo) is unaffected, while left cord is entirely covered with papillomas caused by HPV 69.

Narrow band lighting (2 of 2)
At close range, under narrow band light, the vascular pattern is more strikingly revealed.

HPV 84 & 11

HPV 84 & 11: Series of 5 photos

Chronic hoarseness, papilloma (1 of 5)
60-something man with chronic hoarseness due to these lesions, seen under standard light. Biopsy shows "papilloma" and HPV testing reveals subtypes 84 & 11.

Stippled vascularity, leukoplakia (2 of 5)
At closer range under narrow band light, the stippled "HPV effect" vascularity is seen more clearly. The lesion marked by 'X' in this photo and photo 1 shows a subtle degree of leukoplakia.

Post treatment, voice is very good (3 of 5)
After several micro laryngoscopes, first using cidofovir as an adjuvant, and then avastin, the larynx looks quite clear. Voice is also very good.

Closed phase (4 of 5)
Under strobe light, closed phase of vibration.

Open phase (5 of 5)
Open phase of vibration.

Carcinoma in situ (CIS)

Posted on June 28, 2012 by Dr. Robert Bastian

A lesion comprised of “cancer cells,” but with those cells limited to the lining mucosa and without evidence of extension to adjacent structures. In other words, there is no sign of invasion beyond the mucosa. Carcinoma in situ (CIS) is typically a localized and highly curable precursor to invasive cancer. CIS is sometimes called intraepithelial carcinoma.

In laryngology, CIS is found primarily on the vocal cords themselves, where a tiny, early lesion can change the quality of the voice. In other locations, CIS would ordinarily be “silent.”

Carcinoma

Posted on June 28, 2012 by Dr. Robert Bastian

Carcinoma is a malignancy originating in the tissues that line the surfaces and cavities of the body. See also: cancer, carcinoma in situ, and verrucous carcinoma.

Cancer

Posted on June 28, 2012 by Dr. Robert Bastian

A malignant growth or tumor caused by abnormal and uncontrolled cell division. The hallmark of cancer is its potential ability to invade neighboring tissue or to spread (metastasize) to other parts of the body through the lymphatic system or the bloodstream. Early cancers may have done neither, remaining localized to the tissue of origin. The majority of cancers in the head and neck are classified as carcinomas.

Photos of cancer:

Vocal cord cancer, before and after surgery

Vocal cord cancer (1 of 4)

Squamous cell carcinoma, right vocal cord (left of image), standard light.

Vocal cord cancer, 1 week after surgery (2 of 4)

One week after laser excision. See irregular granulation especially at lower margin of excision.

Vocal cord cancer, 1 month after surgery (3 of 4)

Approximately one month after excision, healing progressing.

Glottic Cancer, Laser Removal

Glottic cancer, laser removal (2 of 3)

Same lesion, at the start of laser removal (OR).

Glottic cancer, laser removal (3 of 3)

Same larynx, after removal is complete. With healing over the next several months, the deficit “fills in” and voice result is often surprisingly good (OR).

Glottic cancer, after surgery: Series of 3 photos

Glottic cancer, after surgery (1 of 3)
After superficial cordectomy, right cord, for early vocal cord cancer, standard light. Note capillary reorientation from normal mostly anteroposterior direction to medial-lateral.

Glottic cancer, after surgery (2 of 3)
Strobe light. Notice excellent matching of the cords at closed phase of vibration, correlating with the patient’s excellent voice quality.

Glottic cancer, after surgery (3 of 3)
Strobe light, open phase of vibration. This view reveals that the left cord oscillates, but the right doesn’t. As long as match is good, and there is no vibratory abnormality of the left cord (e.g. flaccidity, or mucosal abnormality), then voice can be essentially normal.

Vocal cord cancer, before and after surgery: Series of 8 photos

Vocal cord cancer (1 of 8)
Patient from elsewhere, first seen 9 months after radiotherapy, with obvious persistent right vocal cord cancer.

Vocal cord cancer (2 of 8)
Closer view, during phonation, showing deep ulceration and rolled upper and lower border of cancer.

Vocal cord cancer, 1 week after surgery (3 of 8)
One week after aggressive cordectomy, right, including down to inner perichondrium of thyroid cartilage.

Vocal cord cancer, 1 week after surgery (4 of 8)
Phonation, showing that the left vocal cord now has no “partner” against which to vibrate, and this explains the marked breathiness.

Vocal cord cancer, 7 weeks after surgery (5 of 8)
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.

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.

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.

Breaking cancer "rules" intelligently with use of laser: Series of 8 photos

Post radiotherapy stage (1 of 8)
This woman had completed radiotherapy elsewhere many months ago for early vocal cord cancer. Recent biopsy of these lesions shows persistent cancer. At the same time, she is under treatment for unrelated stage IV lung cancer. Standard treatment here would be total laryngectomy.

Laser surgery typically not acceptable (2 of 8)
Under narrow band light and at closer range. Not only due to failure of radiation to cure, but also because this tumor crosses the anterior commissure (where the two vocal cords meet at the bottom of the photo), the widely accepted "rule" is that she should undergo total laryngectomy. The blue lines are located in the same place in the following photo.

Laser removal of tumor with careful followup (3 of 8)
In light of the patient’s uncertain future due to advanced lung cancer, her near-refusal of total laryngectomy, and with detailed inclusion of patient in “breaking the rules” thinking, the tumor was removed with the laser. Tissue margins were negative. Still, tumor behavior is not as predictable as it would be in a previously-untreated patient. Careful followup is therefore critical. Hashmarks show area of removal, to include everything even faintly abnormal-looking and the blue lines are located in the same place in the previous photo.

Second view post laser surgery (4 of 8)
Better view of the anterior commissure, where soft tissue was removed all the way to the inner perichondrium of the thyroid cartilage at the arrow.

Six months post laser surgery (5 of 8)
Nearly 6 months after laser surgery. Healing is complete. No obvious tumor is seen. The patient has developed very serviceable false cord voice (see photos 7 and 8).

Blood vessels stable two months post surgery (6 of 8)
Narrow band light allows more intense monitoring for aberrant blood vessels that might indicate tumor regrowth before there is any visible bulk. Vessels in the area of arrows have been stable for 2 months but require careful comparison with future examination photos.

Open phase of false vocal cord phonation (7 of 8)
False cord phonation, open phase. The true cords cannot oscillate at all due to dense scarring.

Closed phase of false vocal cord phonation (8 of 8)
True vocal cords are obscured by the false cord vibratory closure.

Glottic/vocal cord cancer: Series of 2 photos

Glottic/vocal cord cancer (1 of 2)
Left vocal cord cancer, abducted breathing position, standard light.

Glottic/vocal cord cancer (2 of 2)
Phonation, standard light, shows that the left cord moves normally. Tumor is mostly exophytic (growing outward like broccoli, rather than inward, like an onion).

Supraglottic cancer: Series of 4 photos

Supraglottic cancer (1 of 4)
Middle-aged woman with sore throat, discovered to have a circumscribed exophytic squamous cell carcinoma at the petiole and anterior false cords.

Supraglottic cancer (2 of 4)
Closer view, showing the aberrant tumor vessels especially in the inferior half of the tumor, with less “white-out” from light overexposure.

Supraglottic cancer (3 of 4)
As is often the case, this tumor “respects” the ventricle, meaning it does not cross the plane of the ventricle (entrance at dotted line) to invade the true cords. An instrument could lift the inferior border of the tumor to show that the true cords aren’t invaded; the tumor is simply overlapping them.

Supraglottic cancer (4 of 4)
Under narrow-band lighting, the tumor’s aberrant vessels and its relationship to both the true and false cords are clearer. This is a supraglottic (not transglottic) tumor, likely amenable to outpatient endoscopic laser resection, and management of lymphatic compartments of the neck, depending on individual circumstances, via observation, radiotherapy, or selective neck dissection.

Hypopharyngeal cancer, before and after surgery: Series of 10 photos

Hypopharyngeal cancer (1 of 10)
Years after successful radiotherapy for glottic cancer, during a routine, yearly follow-up examination, a new hypopharyngeal cancer (invasive squamous cell carcinoma) is barely seen, at arrow. (For reference, X marks the same location in the larynx throughout this series.)

Hypopharyngeal cancer (2 of 10)
Trumpet maneuver begins, to splay open the post-arytenoid part of the posterior pharyngeal wall (arrows and dotted lines), as well as the pyriform sinuses on each side. The tumor is now seen clearly. (Note the change of perspective from photo 1, using X as a reference point.)

Hypopharyngeal cancer (3 of 10)
Similar view to photo 2 (still with the trumpet maneuver), but now with the tumor outlined.

Hypopharyngeal cancer (4 of 10)
Closer view than photos 2 and 3 (again, still with the trumpet maneuver), with the tumor still outlined. Radiation is not an option for this tumor because of prior larynx irradiation; an attempt at laser surgery was selected.

Hypopharyngeal cancer: 1 week after surgery (5 of 10)
One week after laser excision of the tumor. Note the widespread redness, and the swollen arytenoid mounds, especially on the right side of the image. Compare with photo 1.

Hypopharyngeal cancer: 1 week after surgery (6 of 10)
Panoramic view, with the patient beginning the trumpet maneuver. The surgical wound is coming into view. Compare with photo 2 (again, using X as a reference point).

Hypopharyngeal cancer: 1 week after surgery (7 of 10)
Maximum trumpet maneuver. Closer view of the surgical wound. Compare with photo 4.

Hypopharyngeal cancer: 1 week after surgery (8 of 10)
View into the left pyriform sinus, where the tumor was most bulky.

Hypopharyngeal cancer: several months after surgery (9 of 10)
Months after laser resection, panoramic view, showing the swallowing “crescent” (within dotted lines), at the upper limit of where the laser resection occurred. There is surgical stenosis at the entrance to the esophagus (shown in the next photo). This stenosis affects swallowing of solid food, but the patient says this is no problem for him, if he eats a little more slowly and chews well.

Hypopharyngeal cancer: several months after surgery (10 of 10)
With the trumpet maneuver, again splaying open the hypopharynx, as in photo 2. Notice the hypopharyngeal/ postcricoid stenosis; the dotted lines represent what would be a normal-sized opening.

Verrucous carcinoma, before and after laser treatment: Series of 5 photos

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 (2 of 5)
During voicing.

Verrucous carcinoma, several weeks after laser treatment (4 of 5)
Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.

Verrucous carcinoma, several weeks after laser treatment (5 of 5)
During voicing. Arytenoid moves, but much of membranous vocal cord has been ablated as intended.

Cancer, HPV Subtype 16, before and after radiation: Series of 5 photos

Cancer: HPV Subtype 16 (2 of 5)
Closer view.

Vocal cord cancer, before and after radiotherapy: Series of 7 photos

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.

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 of 7)
During phonation.

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.

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.

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.

Vocal cord cancer, 2 months after radiotherapy (7 of 7)
Phonation. Compare with photo 3 of this series.

Vocal cord cancer, before, during, and after radiation: Series of 8 photos

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.

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.

Vocal cord cancer, during radiation (3 of 8)
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.

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.

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.

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.

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.

Vocal cord cancer: Series of 1 photo

Vocal cord cancer (1 of 1)
Carcinoma right vocal cord with a large lobule projecting upwards and medial to the false cord, too.

Radiation induced web: Series of 4 photos

Post radiation therapy (1 of 4)
Marked laryngeal swelling and inflammation in a woman undergoing radiation therapy to the neck for recurrent thyroid cancer. The larynx is unavoidably in the radiation field. Note swelling of the left arytenoid (right of photo) as compared with right (left of photo). The X's indicate the location of the arytenoids. In the distance, surrounded by the dotted line, is the web between the vocal cords.

Web formation (2 of 4)
At closer range, the superficial ulceration is indicated by the dotted line. Dashed line indicates where the cords should remain separated but are not, due to formation of a web.

Closer view of ulceration and web (3 of 4)
Closer view. The dotted line is yet again seen around the ulceration and web. Dashed line shows where the cords should remain separate.

Flexible scope used to separate vocal cords (4 of 4)
Using only topical anesthesia with patient in chair and not in the O.R., the flexible scope has been used several times to break the cords apart. Voice is instantly restored. The dotted line helps to see the separation of the forming scar ban.

Larynx cancer managed like "skin cancer": Series of 4 photos

Two years after excision (1 of 4)
Two years after successful laser excision of a right vocal cord cancer, preserving a good voice, despite stiffness of the right cord (left of photo). During this routine followup, slight mid-cord elevation, and subtle haziness catch the eye (within dotted line).

Narrow-band lighting (2 of 4)
Under narrow band light, the elevation and hazy leukoplakia are seen more clearly. Medial-to-lateral capillary reorientation is due to the prior superficial cordectomy.

During thulium laser coagulation (3 of 4)
At the conclusion of thulium laser coagulation. This turns the tissue even whiter, much like when one puts a thin layer of white icing on an already-white cake.

After thulium laser coagulation (4 of 4)
Distant view at the conclusion of laser treatment. The white area will slough off over the next several days.

Vocal cord CA--a case for radiation instead of laser resection: Series of 4 photos

Long term smoker (1 of 4)
Distant view of vocal cords of long term smoker who is chronically hoarse. The tumor is at arrow.

Tumor (2 of 4)
Close-up shows obvious tumor is mostly involving immediate undersurface of the cord. The free margin of both cords is indicated by dotted lines.

Radiation therapy suggested (3 of 4)
Suspicion of submucosal fullness in the anterior subglottis. Laser is generally preferred to radiation for non-bulky tumors but undersurface and anterior subglottic suspicion suggests radiation therapy instead.

Two months later (4 of 4)
Nearly 2 months after completion of radiotherapy, the tumor appears to have melted away; the hazy granularity of the anterior subglottis (arrow) bears careful surveillance.

Scarring after cancer treatment but with very good voice: Series of 4 photos

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.

Prephonatory instant (2 of 4)
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.

Close-up view (4 of 4)
At very close range, medial-to-lateral capillary reorientation -- typical of superficial cordectomy after healing.

Cancer beginning to block airway: Series of 2 photos

Formerly heavy smoker (1 of 2)
Formerly heavy smoker with several months of deteriorating voice. Note that the dark chink where air must pass to enter the trachea is obstructed by an estimated 50% by the tumor. The remaining space remains sufficient for all normal activities without any sense of airway restriction.

Closer view (2 of 2)
At closer range.

Breaking the rules in larynx cancer: Series of 8 photos

Recurrent cancer (1 of 8)
Cancer, recurrent after radiotherapy. Cancer treatment 'rules' dictate a radical anterior commissure resection or more likely, total laryngectomy.

Closer view (2 of 8)
Closer view. The rules just invoked came about because cancer that crosses the anterior commissure is not to be trusted and especially after radiotherapy; cartilage involvement is far more likely; furthermore, laser resection might trigger radionecrosis. With careful patient involvement, an exception to these 'rules' was made here due to concomitant Stage 4 lung cancer of highly uncertain prognosis.

One week post laser resection (3 of 8)
A week after radical laser resection, including to the inner perichondrium of the thyroid cartilage. Wound healing/ radionecrosis is a concern, as is the risk of recurrence when rules are bent.

One year postop (4 of 8)
A year postop. There is no sign of recurrence. As expected, the vocal cords are scarred and will not vibrate. The patient has developed highly functional false vocal cord voice. (See the next four photos.)

True cord phonation (5 of 8)
Making voice, the true cords approximate but do not vibrate.

False vocal cords (6 of 8)
The false cords travel toward each other...

False vocal cord closure (7 of 8)
Here, they have come into full vibratory approximation.

True cords (8 of 8)
False cords separate, again revealing the non-vibrating true cords.

Biopsy of early vocal cord cancer: Series of 3 photos

Chronic hoarseness (1 of 3)
Examination of this man for chronic hoarseness reveals diffusely abnormal-looking tissue on his vocal cords. The area on the upper surface of the right vocal cord (enclosed in dotted circle) appears to be most likely to be diagnostic. Note the bulk, and aberrant blood vessels.

Just before biopsy (2 of 3)
A 2 millimeter cup forceps has been passed through a channel scope and is planted on this area in open position, just before the biopsy.

Cancer finding (3 of 3)
Cup forceps have now been closed to encompass a small fragment of tissue. The pathologist’s answer after looking at this sample under the microscope: cancer

Tumor in trachea: Series of 4 photos

Biopsy (1 of 4)
Tumor growing through wall of trachea, from a paratracheal lymph node. Biopsy forceps are about to close to take a tissue fragment for study.

After biopsy (2 of 4)
After biopsy was taken at arrow. The result: squamous cell carcinoma thought to be an unusual metastasis from unusually aggressive larynx cancer.

Tumor gone (3 of 4)
Soon after radiation therapy, the tumor has melted away, leaving a depression in the tracheal wall.

Slow return (4 of 4)
Eighteen months later, the patient has experienced a fairly durable response, with very slow return of tumor.

HPV 31--> cancer --> cure: Series of 4 photos

Before and after radiation for vocal cord cancer: Series of 4 photos

Bilateral vocal cord cancer (1 of 4)
Bilateral vocal cord cancer in an elderly man. Laser excision is preferred for early cancer, except when, as seen in this larynx, the abnormality is bilateral and diffuse, lacking in obvious boundaries.

"Tumor vessels" (2 of 4)
Note the bulky disease on both sides, with "tumor vessels."

After radiotherapy (3 of 4)
After radiotherapy, more normal contours are restored to the vocal cords. Voice is also much improved. The arrow points to tiny capillaries to serve as reference for the next photo.

Vascular pattern (4 of 4)
At very close range, under narrow band light, this vascular pattern can be carefully monitored for stability. Aberrant, "suspicious" vessels (none seen here) are often the earliest indication of recurrent cancer.

Small, but dangerous!: Series of 4 photos

Post radiotherapy (1 of 4)
After radiotherapy for reported early bilateral vocal cord cancer. No photos are available of the original tumor. Distant view here, showing abnormality below the vocal cords, anteriorly.

Normal voice (2 of 4)
Voice is normal, because closure of the vocal cords and their vibration is not impeded.

Persistent cancer (3 of 4)
Closer view. This is biopsy-proven persistent cancer. Note infiltrative appearance and submucosal component at arrow.

T4 tumor (4 of 4)
Why so dangerous? Radiation resistance can indicate a more aggressive tumor. And in this location, infiltration and even cartilage invasion (direction white arrow) may be present, making this a T4 tumor.

Unusual posterior and transglottic epicenter for larynx cancer: Series of 4 photos

Tumor (1 of 4)
View under standard light shows normal left vocal cord (right of photo) and tumor on right (left of photo). Main bulk is posterior; the cord is mobile, yet (unusually) the tumor is transglottic.

Narrow band light (2 of 4)
Slightly more distant view under narrow band light; accentuation of the vascularity makes the tumor even more easily seen.

Posterior commissure (3 of 4)
Magnified posterior commissure view shows that the main bulk of tumor involves the cartilaginous glottis. This is highly unusual.

A year later (4 of 4)
Laser excision was satisfying except that the deep margin was the cricoid cartilage and therefore radiation therapy followed laser excision for added "safety." Laser excision and radiotherapy were 9 years prior to this posting, at which point he remained free of disease.

Nice try, but on to radiation: Series of 4 photos

Vocal cord lesion (1 of 4)
Middle aged man with hoarseness and a left vocal cord lesion (right of photo) suspicious for cancer. After extensively educating the patient about options he would have if this were proven to be cancer, a single trip to the O.R. was planned for both frozen section, and possible definitive laser excision.

Closer view (2 of 4)
Though this looks bulky, some "large" tumors can be removed definitively with the laser, if they are mostly exophytic (growing outwards) rather than endophytic (deeply infiltrating).

Removal of tumor (3 of 4)
Frozen section was positive for squamous cell cancer, and much of the tumor was removed, but an endophytic (infiltrative) growth pattern diverted the plan to radiation therapy.

Nice try, but on to radiation (4 of 4)
If significantly more vocal cord were removed, voice might also have been excessively compromised.

Progressive cricoarytenoid joint fibrosis/ fixation as a late complication of radiation: Series of 4 photos

25 years post radiotherapy (1 of 4)
During 25 years since radiotherapy for vocal cord cancer, voice had been “80%” and breathing normal. In recent years, voice is deteriorating; breathing also seems restricted during exertion. During “quiet breathing,” the vocal cords are in only partial abduction, due to fixation/ partial fixation of the crico-arytenoid joints. This glottic chink for breathing is likely less at night during sleep, explaining noisy breathing and the need for CPAP.

Fibrosis (2 of 4)
Here, the patient is sniffing, in order to reveal maximum possible abduction. Note that the right vocal cord (left of photo) seems “frozen” but not paralyzed (no atrophy) due to fibrosis of the right cricoarytenoid joint. The left vocal cord (right of photo) lateralizes incompletely. Note as well, post-radiation capillary ectasia.

Closed phase (3 of 4)
Under strobe light, closed phase of vibration. The left cord can move to the midline, and there is no sense of atrophy of either cord.

Open phase (4 of 4)
Open phase of vibration shows that only the left vocal cord mucosa (right of photo) is flexible, and is the source of all of the patient’s voice. The right cord mucosa (left of photo) is stiff and non-vibrating at all pitches. Without an examination from 25 years earlier, it is unknown where this represents early post-treatment stiffness (scarring from biopsy, etc.) or whether it is also the result of progressive fibrosis.

Progressive radiation fibrosis effects on the larynx and a solution to some of it: Series of 8 photos

Forty years post-radiation (1 of 8)
This photo is taken forty years after curative radiation for a vocal cord cancer. Four decades of progressive radiation fibrosis (“leatherization”) has taken away arytenoid movement so that this is the maximum opening. The patient is exercise-intolerant and makes loud inspiratory breathing noises while sleeping. Her voice is also very poor.

Involuntary inspiratory voice (2 of 8)
With sudden inspiration, the darker mucosa (at the arrows) indraws and vibrates, making an involuntary inspiratory voice.

Only capable of high pitch (3 of 8)
Other than a stage whisper, she can only make a very high pitch, because the only mucosa capable of vibration is the small segment indicated by the arrows.

Open phase vibration (4 of 8)
Again under strobe light, this is the open phase of vibration, with arrows again indicating the short segment of mucosa that can oscillate.

One week post-commissuroplasty (5 of 8)
A week after posterior commissuroplasty, the patient’s breathing is much improved. Despite the distant view, the “cookie bites” taken from the posterior cords are visible.

Rapid inhalation, closer view (6 of 8)
In a much closer view, the posterior vocal cord divots are seen well. The segment of flexible mucosa is indrawing here as the patient inhales rapidly (at arrows).

Three months post-surgery (7 of 8)
Three months after the laser surgery, the patient continues to say the improvement of breathing is “large.” In this distant view the full reason why is not seen.

Closer view, post-surgery (8 of 8)
In a closer view, as is always the case after complete healing, the divots are smaller than just after surgery.

Evolution of the wound after laser removal of a vocal cord cancer: Not pretty at first, but voice result can be very good: Series of 8 photos

Vocal cord cancer (1 of 8)
Bulky but superficial right vocal cord cancer (arrow, left of photo).

Voice-making with tumor (2 of 8)
Voice-making position. Notice the more lateral turning of the right vocal process (left of photo) as compared with the left (right of photo). As the remaining series shows, it is impossible to know if this is compensation for the bulk of tumor, or weakness of the LCA muscle.

One week post-removal (3 of 8)
A week after definitive removal, swelling, early granulation, and a division of the wound into upper and lower “lips” that must bind together with healing.

Voice-making, post-removal (4 of 8)
Note again the lateral turning of right vocal process (arrow, left of photo).

Six weeks post-op (5 of 8)
Six weeks after surgery, the wound is “bound together,” and there is a residual granuloma on the upper surface anteriorly (arrow).

Voice-making, post-op (6 of 8)
Making voice, there is still that peculiar lateral turning of the vocal process on the right (left of photo).

Four months post-op (7 of 8)
Now a full 4 months since laser excision, the cord is fully healed though still pink as expected. The anterior upper surface is coated with mucus.

Voice-making, four months post-op (8 of 8)
Making voice, again that lateral deviation of the right vocal process (arrow, left of photo). Voice is very functional but a little weak. Vibratory blur is greater for left than right cord.

Laser can beat cancer and spare voice even after radiotherapy failure: Series of 4 photos

(1 of 4)
Eight years after radiotherapy for early vocal cord cancer, cancer has returned in a man who never stopped smoking. Radiotherapy is no longer an option. Here, we have bilateral disease.

(2 of 4)
At closer range under narrow band light, areas of leukoplakia and stippled vascularity are seen more clearly; all of this must be removed. The options are laser excision, partial laryngectomy, and total laryngectomy. Laser excision was selected as the "next step."

(3 of 4)
10 weeks after laser excision, healing is nearly complete. Stippled vascularity is no longer seen; the medial-to-lateral reorientation of capillaries often seen after laser excision is seen especially on the right vocal cord (left of photo).

(4 of 4)
Now at 18 weeks after laser excision, healing is truly complete. Even under narrow band light and at close range, no vascular abnormality or leukoplakia is seen. Voice is remarkably good, without audible "effort," or syllable dropouts. Obviously, close follow up is required.

How a vocal cord heals after laser removal of a cancer: Series of 6 photos

(1 of 6)
After biopsy performed elsewhere revealed squamous cell carcinoma, this right vocal cord cancer (left of photo) is scheduled to be treated for cure via laser excision.

(2 of 6)
A week after laser excision, the typical upper and lower "lips" swell at the margins of resection will need to heal back together to re-establish a normal vocal cord contour.

(3 of 6)
As the vocal cords approach each other in preparation for producing voice, the upper and lower lips with central depression are seen more clearly.

(4 of 6)
At approximately 2 months after laser excision, healing is nearly complete and voice very functional. There is a round granuloma (exuberant healing response) that will soon fall off spontaneously. Every patient is told about possible granulation of this sort, so that they do not worry that this is a tumor recurrence.

(5 of 6)
A year after surgery, the patient's voice can pass for normal. Under strobe light, this closed phase of vibration shows the good match of the vocal cord margins. The regenerated mucosa of the right (upper part of photo) vocal cord has a typically abnormal (but healthy) post-laser capillary pattern.

(6 of 6)
Here during the open phase of vibration, one can see that the right vocal cord is stiff (as expected after laser surgery of any depth) and does not vibrate well. Voice sounds virtually normal, however, due to the precise match of the margins and normal left vocal cord vibration (see again, photo 5). At the time of this posting, this person has remained free of disease for 8 years, and has no sense of vocal limitation.

Videos:

https://youtu.be/ValnxOGGoPo

Early Vocal Cord Cancer | Introduction and Treatment Options (https://youtu.be/ValnxOGGoPo)

Early Vocal Cord Cancer
This video provides an introduction to early vocal cord cancer (stages 1 and 2) and compares the two main treatment options, laser surgery and radiation therapy.

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Symptoms and risks of recurrent respiratory papillomatosis:

Characteristics of the growths:

Treatment for recurrent respiratory papillomatosis:

Photos:

Videos:

Photos:

Chondroma of thyroid cartilage: Series of 4 photos

Chondroma of thyroid cartilage (1 of 4)

Chondroma of thyroid cartilage (1 of 4)

Chondroma of thyroid cartilage (2 of 4)

Chondroma of thyroid cartilage (2 of 4)

Chondroma of thyroid cartilage (3 of 4)

Chondroma of thyroid cartilage (3 of 4)

Chondroma of thyroid cartilage (4 of 4)

Chondroma of thyroid cartilage (4 of 4)

Amyloidosis in the larynx:

Treatment for laryngeal amyloidosis:

Photos:

Amyloidosis, before and after debulking: Series of 4 photos

Amyloidosis, before debulking (1 of 4)

Amyloidosis, before debulking (1 of 4)

Amyloidosis, before debulking (2 of 4)

Amyloidosis, before debulking (2 of 4)

Amyloidosis, before debulking (3 of 4)

Amyloidosis, before debulking (3 of 4)

Amyloidosis, after debulking (4 of 4)

Amyloidosis, after debulking (4 of 4)

Amyloidosis: Series of 1 photo

Amyloidosis (1 of 1)

Amyloidosis (1 of 1)

Amyloidosis, before and after debulking: Series of 8 photos

Amyloidosis, before debulking (1 of 8)

Amyloidosis, before debulking (1 of 8)

Amyloidosis, before debulking (2 of 8)

Amyloidosis, before debulking (2 of 8)

Amyloidosis, before debulking (3 of 8)

Amyloidosis, before debulking (3 of 8)

Amyloidosis, before debulking (4 of 8)

Amyloidosis, before debulking (4 of 8)

Amyloidosis, after debulking (5 of 8)

Amyloidosis, after debulking (5 of 8)

Amyloidosis, after debulking (6 of 8)

Amyloidosis, after debulking (6 of 8)

Amyloidosis, after debulking (7 of 8)

Amyloidosis, after debulking (7 of 8)

Complete healing (8 of 8)

Complete healing (8 of 8)

Proteinaceous deposits of primary laryngeal amyloidosis can occur anywhere and “everywhere” in the larynx: Series of 4 photos

Airway Passage (1 of 4)

Airway Passage (1 of 4)

Submucosal Masses (2 of 4)

Submucosal Masses (2 of 4)

Diffuse Subglottic Infiltration (4 of 4)

Diffuse Subglottic Infiltration (4 of 4)

Amyloid Deposits (3 of 4)

Amyloid Deposits (3 of 4)

Videos:

Photos:

Photos:

Common Questions About HPV

Q: What is the relationship between the terms RRP, HPV, and Papilloma?

Q: HPV apparently has different subtypes. What can you tell me about them?

Q: I have a low-risk subtype of HPV. Can you explain what this means?

Photos:

Subtype 6

Subtype 11

Subtype 16

Subtype 18

Subtype 31

Subtype 44

Subtype 45

Subtypes 33 & 45

Subtype 55

Subtype 69

HPV 84 & 11

Photos of cancer:

Vocal cord cancer, before and after surgery

Vocal cord cancer (1 of 4)

Vocal cord cancer (1 of 4)