Vocal Cord Synechia

Vocal cord synechia is a strand of scar tissue that tethers the vocal cords to each other. It can prevent the vocal cords from opening fully for breathing.

A synechia can also form in other parts of the body. (Note the subglottic synechia shown below.)


Photos:

Vocal Cord Synechia: before, during, and after surgery

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Post-intubation synechia

Vocal Cord Synechia (1 of 9)

Post-intubation synechia tethers the arytenoid cartilages together. This patient is tracheotomy-dependent.
Vocal cord synechia during surgery

Vocal cord synechia, during surgery (2 of 9)

Operative view of synechia ("v" of the vocal cords is inverted). Notice that the vocal cords are completely approximated because the synechia has bound them together.
Tiny forceps are separating the cords

Vocal cord synechia, during surgery (3 of 9)

Tiny forceps is separating the cords (arrows) and more clearly shows the extent of the synechia.
Micro-scissors in position to divide the synechia cleanly

Vocal cord synechia, during surgery (4 of 9)

Micro-scissors in position to divide the synechia cleanly. For perspective, the blade of the scissors is only a few millimeters long.
Vocal cord synechia

Vocal cord synechia, during surgery (5 of 9)

After division of the synechia and topical application of an anti-scarring agent.
Vocal cord synechia after surgery

Vocal cord synechia, after surgery (6 of 9)

Five days after surgery. Vocal cords are able to separate for breathing, and the tracheotomy tube can be removed. Compare with photo 1.
healed larynx after release of synechia

Vocal Cord Synechia, after surgery (7 of 9)

Completely healed larynx after release of synechia. Abduction completely restored.
vocal cords are coming together for phonation

Vocal cord synechia, after surgery (8 of 9)

As the vocal cords are coming together for phonation (not yet completely adducted).
Vocal cord synechia

Vocal cord synechia, after surgery (9 of 9)

Closer view. Can hardly see where the synechia was. Compare again with photo 1.

Ossified synechia resists thulium laser

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Ossified synechia

Ossified synechia (1 of 8)

This 75-year-old woman suffered complications after open heart surgery, and was intubated for three weeks. Nearly two years later, she remains short of breath and bothered by difficulty mobilizing secretions. On initial examination, a synechia was identified; at patient request, microlaryngoscopy was scheduled both to divide the synechia and to inject voice gel into the deficient posterior commissure. At surgery, a view sufficient to divide the synechia was not possible. The patient was rescheduled for office-based thulium laser division of the synechia.
Tip of glass fiber near the Ossified Synechia

Ossified Synechia, during first laser treatment (2 of 8)

Close-range view of the synechia. The tip of the glass fiber through which laser energy will be delivered is seen just inferior to the synechia.
Laser energy reveals bone underneath

Ossified synechia, during first laser treatment (3 of 8)

As the synechia is divided, a core of bone formation is exposed. More than half of the laser energy has been delivered to this spar of bone, yet it will not yield. The tip of the scope has also been flexed against the synechia to no avail. A second attempt with higher energy laser has been scheduled.
Ossified synechia 4 months later

Ossified synechia, 4 months later (4 of 8)

Four months later. The synechia remains, and there is residual granulation tissue on its undersurface. It's not yet known whether the spar of bone is still present. Compare with photo 2.
Second surgery attempt of thulium laser

Ossified synechia, 4 months later (5 of 8)

Now, with the thulium laser, beginning a second attempt at dividing the synechia.
Thulim laser reveals no bone remaining in ossified synechia

Ossified synechia, 4 months later (6 of 8)

The spar of bone is not found within the synechia (apparently turned to ash during the original procedure four months earlier), and now the scar band is divided. The patient could feel the difference in her breathing immediately.
synechia is now gone 6 months later

Synechia gone, 6 months later (7 of 8)

Six months after the initial laser treatment for this patient's bone-containing synechia. The synechia is now gone, with only a small residual projection remaining, left of photo. The vocal cords also separate more widely, to a wider "V".
divots from pressure necrosis of the endotracheal tube remain evident

Synechia gone, 6 months later (8 of 8)

During phonation. The divots from pressure necrosis of the endotracheal tube remain evident. In spite of them, the patient's voice is excellent.

Vocal cord synechia

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Vocal cord synechia

Vocal cord synechia (1 of 4)

Note that the vocal cords cannot fully abduct, due to the presence of a synechia, which tethers them to each other posteriorly.
Vocal cord synechia

Vocal cord synechia (2 of 4)

Same patient during phonation.
Vocal cord synechia

Vocal cord synechia (3 of 4)

Same patient at closer range.
Vocal cord synechia

Vocal cord synechia (4 of 4)

Same patient. Synechia in full view.

Intubation injury, including a subglottic synechia

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View of the vocal cords in abducted position

Intubation injury, including a subglottic synechia (1 of 2)

View of the vocal cords, in abducted position, in a patient with voice change after long-term intubation due to brain injury. Injury of the left posterior vocal cord (right of image) can be seen, where pressure from the breathing tube caused an erosion or divot (arrow). The synechia is not yet visible from this viewing perspective.
posterior synechia

Intubation injury, including a subglottic synechia (2 of 2)

Same patient, just below the level of the cords. This synechia, located posteriorly, is additional evidence of breathing tube injury.

Synechia hidden by overhanging arytenoid superstructure

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Maximum possible abduction of the vocal cords

Synechia hidden by overhanging arytenoid superstructure (1 of 4)

Maximum possible abduction of the vocal cords, as seen a few months after an illness that required endotracheal intubation for 3 weeks. This person experienced noisy breathing with any significant exertion.
involuntary inspiratory phonation

Synechia hidden by overhanging arytenoid superstructure (2 of 4)

With elicited sudden inhalation the inspiratory air draws the vocal cords together, and the result is involuntary inspiratory phonation.
overhanging arytenoid superstructure

Synechia hidden by overhanging arytenoid superstructure (3 of 4)

Close-up view of the posterior vocal cords reveal a synechia or scar band tethering the vocal cords to each other and preventing their abduction. This kind of injury can exist in isolation; it can also occur together with cricoarytenoid joint ankylosis.
Synechia hidden by overhanging arytenoid superstructure

Synechia hidden by overhanging arytenoid superstructure (4 of 4)

An even closer view of the synechia.

Nasal and inter-arytenoid synechiae, with subglottic stenosis in forme fruste Wegener’s

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inflammatory adhesion in left nasal cavity

Nasal cavity (1 of 4)

View in left nasal cavity, showing inflammatory adhesion between septum and turbinate/ lateral wall of nose. Note intense erythema at “e.” Dotted line shows where normal separation would be seen.
adhesion of septum and turbinates

Closer view (2 of 4)

Closer, brighter view, again with dotted line where there should be no tissue bridge, but instead separation between septum and turbinates. This adhesion is asymptomatic, and therefore does not need to be treated.
Panoramic view of larynx

Panoramic view (3 of 4)

Panoramic view of larynx, showing adhesion between arytenoid cartilages indicated by vertical hashed lines. Horizontal dashed line is for reference with the next photo.
interarytenoid synechia is no longer seen after dilation

Post dilation (4 of 4)

After dilation, the interarytenoid synechia is no longer seen. Subglottic stenosis is present but not shown in this series.

Ulcerative laryngitis and resulting synechia – fixed!

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a synechia attaching the cords together

Synechia (1 of 3)

This woman developed a sore throat and lost her voice a week after a chemotherapy treatment for her metastatic breast cancer. Here, 6 weeks later, note the hazy area representing resolving “ulcerative” laryngitis (surrounded by tiny dotted line). There is a synechia attaching the cords together.
slight separation of attached vocal cords

Attempted to detach (2 of 3)

The flexible scope has been used once to “twang upwards” from below in order to detach the cords from each other. At the arrow, slight separation can be seen.
adhesion has been released

Successfully detached (3 of 3)

Just after the second attempt. That is, for the second time, the scope was passed below the cords, angulated sharply underneath the synechia, and then pulled upwards. The adhesion has been released. Voice is instantly and dramatically restored (though still hoarse, of course).

Posterior Commissure Synechiae

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tissue band tethers the vocal cords closer together

Tethered vocal cords (1 of 5)

This man has right vocal cord paralysis and a history decades ago of Teflon injection into the right vocal cord, resulting in posterior commissure synechiae. He is short of breath, partly due to the tissue band and partly because it tethers the vocal cords closer together than they would otherwise need to be as seen in photo 4 after the band is removed. See also photo 5.
Tethered vocal cords

Tethered vocal cords (2 of 5)

At closer range.
thulium laser fiber is touching the synechiae

Before laser removal (3 of 5)

The thulium laser fiber (F) is touching the synechiae, with laser energy about to be delivered.
thulium laser division of the band

Immediately after laser (4 of 5)

This is just after the thulium laser division of the band using topical anesthesia only, with patient sitting in a chair.
Vocal cords free of synechiae

One month post-op (5 of 5)

A month later, no residue of the synechiae is seen, and the vocal cords can spring farther apart than in photo 1.

Difficulty Breathing After A 3-day Intubation

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granulation tissue at the posterior commissure

Noisy, restricted breathing following intubation (1 of 5)

This teenager was intubated for 3 days due to tongue swelling. Breathing became noisy and restricted approximately 6 weeks later. Note that the vocal cords do not abduct fully and there is what appears to be granulation tissue at the posterior commissure (anterior asterisk).
vocal cords come into contact

Normal voice (2 of 5)

The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.
small tract is seen posterior to the granulation

At close range (3 of 5)

At very close range within the posterior commissure, a small tract is seen posterior to the "granulation" which is now seen more clearly to be a broad-based synechiae with asterisks marking anterior and posterior limits.
posterior tract

At even closer range (4 of 5)

An even closer view verifies a posterior tract, and this makes it less likely that the cricoarytenoid joints are also injured.
small superficial-looking scar

Mucosa-only scar (5 of 5)

This view is taken with the scope passed just between the vocal cords and just anterior to the synechiae and angled directly posteriorly. A small superficial-looking "mucosa-only" scar is seen bilaterally, surrounded by dotted line. It can be confidently predicted that when the synechiae is released, the arytenoid cartilages will likely be able to abduct fully.

Videos:

https://youtu.be/yF9pU_CncW4
Vocal Cord Synechia
Vocal cord synechia is a condition wherein a scar band tethers the vocal cords to each other. Therefore, the vocal cords cannot fully open for breathing. This video provides a clear example — using laryngeal videostroboscopy — of a vocal cord synechia.

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

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:

  1. Both the “carpet-variant” and wart-like growths are lesions that sometimes appear, either independently or together, in patients who have HPV;
  2. 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;
  3. Both the “carpet-variant” and wart-like growths can disrupt voice function;
  4. 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:



























Videos:

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

Laryngocele

A disorder in which the laryngeal saccule is inflated and becomes abnormally enlarged. A common symptom of a laryngocele is hoarseness.

How it develops:

The laryngeal saccule, or laryngeal appendix, is a very small blind sac—a dead-end corridor, so to speak—which is located just above the vocal cords, one on each side, and is lined with glands that supply lubrication to the cords. When a person makes voice, it is possible for a little bit of the air being pushed up out of the trachea to slip into this saccule. If over time enough air enters the saccule with enough force, the saccule may begin to be inflated and stretched out, leading to a laryngocele.

In some cases, the air that slips into and inflates the laryngocele will slip back out again as soon as the person stops making voice, so that the laryngocele abruptly inflates and deflates with each start and stop of speech or voice-making. (The photos and video below are an example of this.) In other cases, the air cannot exit as easily, but it may be reabsorbed slowly during quiet times or during sleep—only to be inflated again at the next instance of more active speaking.

Laryngocele vs. saccular cyst:

A much more common disorder of the laryngeal saccule (compared with a laryngocele) is a saccular cyst, which can occur if the entrance to the laryngeal saccule becomes blocked. In this scenario, air is absorbed, but secretions build up and gradually expand the saccule.

Symptoms and treatment for laryngocele:

A common symptom is hoarseness, because while the saccule is inflated, it may press press down on the vocal cords, not allowing them to vibrate freely, or it may block the laryngeal vestibule just above the cords and partially muffle the sound produced by the cords. Standard treatment is surgical removal, through one of two approaches: a small incision on the neck that leads into the larynx from the outside, or a laryngoscope that is inserted through the mouth and down into the larynx so that the laryngocele can be removed using a laser.


Photos:





Videos:

Laryngocele: A Cause of Hoarseness
A laryngocele is a disorder of the saccule, or laryngeal appendix, in which air abnormally expands it. Watch this video to see how a laryngocele behaves in real-time, and why that can affect the voice.

Glottic Sulcus

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

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


Photos:

Glottic Sulcus, before and after surgery

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a partial ring of capillaries around the glottic sulcus

Glottic sulcus, before surgery (1 of 3)

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

Glottic sulcus, before surgery (2 of 3)

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

Glottic sulcus, after surgery (3 of 3)

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

Congenital glottic sulcus and bowing, before and after injection

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Glottic sulcus

Glottic sulcus (1 of 10)

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

Glottic sulcus (2 of 10)

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

Glottic sulcus (3 of 10)

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

Glottic sulcus (4 of 10)

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

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

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

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

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

Voice gel injection (7 of 10)

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

Voice gel injection (8 of 10)

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

After the injection (9 of 10)

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

After the injection (10 of 10)

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

Glottic Sulcus

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Faint line of glottic sulcus

Glottic sulcus, closed (2 of 2)

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

Glottic sulcus, open (1 of 2)

Same patient, while instrument holds one lip of the sulcus, splaying it open to reveal the empty “pocket” (OR).
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Bilateral glottic sulcus

Glottic sulcus (1 of 2)

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

Glottic sulcus (2 of 2)

Same patient. Note the tiny opening of the sulcus right at the margin of the left vocal cord.
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Mucosal bridge / glottic sulcus

Glottic sulcus (1 of 2)

Mucosal bridge / glottic sulcus.
Glottic sulcus

Glottic sulcus (2 of 2)

Same patient, showing sulci (arrows) under strobe light.
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Glottic sulcus

Glottic sulcus (1 of 2)

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

Glottic sulcus (2 of 2)

Note that the "lips" of the glottic sulcus are closed; compare to image #1. Also see the video for this.
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Shallow sulcus

Glottic sulcus (1 of 1)

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

Glottic Sulcus and Glottic Furrow

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Glottic sulcus and glottic furrow

Glottic sulcus and glottic furrow (1 of 4)

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

Glottic sulcus and glottic furrow (2 of 4)

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

Glottic sulcus and glottic furrow (3 of 4)

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

Glottic sulcus and glottic furrow (4 of 4)

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

Glottic Sulcus Operation

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Glottic sulcus

Glottic sulcus operation (1 of 7)

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

Glottic sulcus operation (2 of 7)

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

Glottic sulcus operation (3 of 7)

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

Glottic sulcus operation (4 of 7)

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

Glottic sulcus operation (5 of 7)

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

Glottic sulcus operation (6 of 7)

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

Glottic sulcus operation (7 of 7)

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

Surgical Removal of Glottic Sulcus

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cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa

Surgical removal of glottic sulcus (1 of 4)

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

Surgical removal of glottic sulcus (2 of 4)

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

Surgical removal of glottic sulcus (3 of 4)

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

Surgical removal of glottic sulcus (4 of 4)

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

Open Cyst or Sulcus?

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nuances besides the vascularity and hyperemia

Hoarse voice (1 of 4)

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

Open Cyst Definition (2 of 4)

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

Closed phase (3 of 4)

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

Open phase (4 of 4)

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

Sulcus and Segmental Vibration

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lateral lip of her glottic sulci

Glottic sulci (1 of 4)

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

Open phase (2 of 4)

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

Closed phase (3 of 4)

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

Segmental vibration (4 of 4)

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

Open Cyst and Sulcus; Normal and Segmental Vibration

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Breathing position of the vocal cords of a very hoarse actor

Margin swelling (1 of 6)

Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.
right sulcus

Narrow band light (2 of 6)

Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.
pen phase of vibration

Open phase, strobe light (3 of 6)

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

Closed phase, same pitch (4 of 6)

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

Segmental vibration (5 of 6)

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

Closed phase (6 of 6)

The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.

Glottic Furrow—Not Just Bowing and Not Glottic Sulcus

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Bowing vocal cords with furrows

Bowing vocal cords with furrows (1 of 4)

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

"Closed" phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.
open phase shows linear groove just below the margin of each cord.

Open phase (3 of 4)

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

Glottic sulcus is visible (4 of 4)

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

Mottled Vocal Cord Mucosa May Hide Glottic Sulci

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Vocal cord swelling

Vocal cord swelling and mucosa (1 of 4)

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

Same view under strobe light (2 of 4)

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

Closed phase (3 of 4)

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

Glottic sulcus is visible (4 of 4)

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

A Case That Clearly Shows the Relationship Between Cyst & Sulcus

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white lesion on right vocal cord

White Lesion on Right Vocal Cord (1 of 6)

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

White Lesion Under Strobe Light (2 of 6)

Under strobe light and with higher magnification, the open phase of vibration shows this lesion as a white nubbin protruding from a fossa.
lesion in closed phase of vibration

White Lesion Under Strobe Light (3 of 6)

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

White Lesion Removed (4 of 6)

After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”
trough from which the lesion was removed

Vocal Cords (5 of 6)

At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.
closed phase of vibration post removal

Vocal Cords without Lesion (6 of 6)

The closed phase of vibration. Compare with photo 3.

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

Stenosis

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

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


Photos of Stenosis:













 




















Videos of Stenosis:

Tracheal Stenosis: Before and After
In this video, trachea (windpipe) blockage causes shortness of breath until the narrowed segment is removed. You will see views of the trachea before and after surgical repair.

Post-Radiation Hypopharyngeal Stenosis
People with larynx or pharynx (voice box or throat) cancer often undergo radiation therapy as part of their treatment regimen. An uncommon complication is stenosis (narrowing, scarring) of the entrance to the upper esophagus at the junction of the throat and esophagus. This video provides an example of this disorder.

Mucosal Chatter

Mucosal chatter is an audible phenomenon of injured vocal cord vibration. It is commonly heard in the softly-sung upper voice of persons with nodules, polyps, etc.

Hoarseness or roughness are broad and nonspecific descriptors useful only for severe injuries. Small injuries that are nevertheless impairing the singing range may leave the speaking voice sounding normal. I suppose “hoarseness of singing range” could be used, but again, that would be an unsophisticated and basic description of vocal phenomenology. To hear more useful phenomena of injury, we elicit and thereby investigate the upper range of singing (even in nonsingers) because high, soft singing makes the phenomenology apparent.  This is why we have described “vocal cord swelling checks” and created a video to teach how to elicit them, and also how to evaluate and communicate the phenomenology that results. In particular, delays of phonatory onset (“onset delays”) above approximately C5 (523 Hz) may indicate mucosal injury even when speaking voice sounds normal. Also heard is air-wasting, where there is a “scratchiness” to the excess airflow. Segmental vibration is also a common audible phenomenon of a mucosal disorder can also be easily taught and recognized.

Vocal cord mucosal chatter adds an extremely rapid “shudder” on top of the pitch of the voice. I have used “chatter” rather than “shudder” because the latter suggests a lower frequency than the former. It could be called a very fine-grained diplophonia…but typical diplophonia, caused by independent vibrating segments, is a much grosser vocal phenomenon. While chatter is more subtle, once it is pointed out and taught briefly, most people can easily distinguish between onset delays, diplophonia, segmental vibration, the transient “squeaking” of a micro-segmental vibration,  the crackling sound of mucus dancing on the vocal cords, and “chatter.”  Those who master recognition of these phenomena can easily communicate them to colleagues. For our purposes, let me stress again that the above phenomena—and chatter in particular—do not happen in the normal larynx, where vocal cord margins match perfectly and the mucosa oscillates normally.  When heard—even in the person with a normal speaking voice—the examiner can strongly suspect a mucosal abnormality even before examining the vocal cords.  In fact, where these phenomena are heard and initial examination looks normal, it would be a good idea to “look harder.”

Patient examples:

Videos:

SLAD-R

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


Photos:



Videos:

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

Forme fruste Wegener’s granulomatosis

An incomplete or frustrated form (forme fruste) of Wegener’s granulomatosis,* which we believe to be the cause behind some cases of inflammatory subglottic or tracheal stenosis. Unlike full-fledged Wegener’s, this forme fruste variant may or may not necessarily involve the sinus and nasal cavities, and in the author’s caseload of about 60 patients, it has not ever progressed to involve the lungs and kidneys. Such patients can go for years with only the need for intermittent dilation of the subglottic or tracheal narrowing. This disorder may be the same as what some call “idiopathic subglottic stenosis,” for which some have recommended cricotracheal resection and reanastomosis as treatment.

*Newer terminology is granulomatosis with polyangiitis (GPA)


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Videos:

Wegener’s Granulomatosis: Forme Fruste (incomplete expression)
Wegener’s granulomatosis is a rare autoimmune disorder in which blood vessels become inflamed. The inflammation causes swelling and scarring. Three typical organs attacked are sinus/nasal cavities, lungs, and kidneys. In the forme fruste variant, it is mostly an inflammatory stenosis (narrowing) of the area below the vocal cords, and also the trachea. A person becomes short of breath and begins to make harsh breathing sounds due to the narrowed passageway. This is an example of one means of management: dilation of the narrowed area during a very brief general anesthetic in an outpatient operating room.

Phases of swallowing

The different phases that together make up the act of swallowing. Actually, swallowing is a rapid and seamless act, and dividing that act into distinct phases is somewhat arbitrary. But one simple scheme for the phases of swallowing, among many that have been codified, would be:

Phases of swallowing:

  1. Oral preparatory phase: food is masticated (chewed), mixed with saliva, and then “gathered” into a softened mass (called a bolus) between the tongue and palate.
  2. Oral transit phase: the bolus is sent posteriorly toward the base of the tongue. This sending of the bolus is a volitional (technically conscious) action, though it may be performed without really thinking about it.
  3. Oro-pharyngeal phase: the bolus arrives at the base of the tongue and triggers the swallow reflex, which is non-volitional, or automatic.
  4. Pharyngeal phase: the bolus travels down from the base of the tongue past the closed and elevated larynx and to the entrance of the esophagus. This is a continuation of the automatic swallow reflex.
  5. Esophageal phase: the cricopharyngeus muscle relaxes to allow the bolus into the upper esophagus, from where it is passed downward by waves of muscle contraction through the lower esophageal sphincter (LES) and into the stomach. All of the muscular action in this phase is also non-volitional.

Videos:

https://youtu.be/_dBPKBg8jXM
Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).

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.


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Videos:

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