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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Vocal Cord Synechia (1 of 9)

Post-intubation synechia tethers the arytenoid cartilages together. This patient is tracheotomy-dependent.

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.

Vocal cord synechia, during surgery (3 of 9)

Tiny forceps is separating the cords (arrows) and more clearly shows the extent of the synechia.

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, during surgery (5 of 9)

After division of the synechia and topical application of an anti-scarring agent.

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.

Vocal Cord Synechia, after surgery (7 of 9)

Completely healed larynx after release of synechia. Abduction completely restored.

Vocal cord synechia, after surgery (8 of 9)

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

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 (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.

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.

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 (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.

Ossified synechia, 4 months later (5 of 8)

Now, with the thulium laser, beginning a second attempt at dividing the 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 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".

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 (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 (2 of 4)

Same patient during phonation.

Vocal cord synechia (3 of 4)

Same patient at closer range.

Vocal cord synechia (4 of 4)

Same patient. Synechia in full view.

Intubation Injury, Including a Subglottic Synechia

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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.

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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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.

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.

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.

Nasal and Inter-arytenoid Synechiae, with Subglottic Stenosis in Forme Fruste Wegener’s

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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.

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 (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.

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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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.

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.

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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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.

Before laser removal (3 of 5)

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

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.

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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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).

Normal voice (2 of 5)

The vocal cords can come into contact as shown here, consistent with her normal-sounding voice.

At close range (3 of 5)

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

At 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.

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:

Humility Before the HPV Virus—A Recurrence of Papillomas at Ten Years

HPV infection is considered chronic, and causes recurrent growth of papillomas in the larynx. Still, we sometimes see what appear to be cures, or at least long-term remissions. That appears to be the case here. After an 8 year interval of perfect voice, the patient had a sudden increase of hoarseness occurring in the few weeks prior to the last examination below. This is an illustration of why we often say to a patient who appears to be cured, “You may be cured, but we usually say “long term remission.”  This patient’s scenario is not rare. Was her longterm, 8-year remission due to meticulous surgery?  Cidofovir? Her immune response?  It is impossible to say if it was one or all of these factors.

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Stippled Vascularity (1 of 8)

In a somewhat distant view from 10 years earlier, under standard light, both vocal cords appear to be covered with stippled rather than (normal) linear or curvilinear vascularity. The diagnosis (biopsy confirmed): laryngeal papillomatosis aka RRP (recurrent respiratory papillomatosis), type 6.

HPV infection (2 of 8)

A somewhat closer view under blue-green narrow band light accentuates the stippled vascularity so typical of HPV infection. Both true cords are covered and there are patches on the false cords (arrows).

Stippled vascularity (3 of 8)

After surgery and cidofovir injection a year earlier, voice remains normal to the patient. Sharp eyes can pick up a tiny focus of stippled vascularity of the right cord (left of photo).

HPV vascular effect (4 of 8)

At closer range with narrow band light, the HPV vascular effect on the right cord is made more obvious (arrows). The patient requested a “curative mode” additional surgery to clear up this tiny residue and inject cidofovir.

16 months later (5 of 8)

16 months later, voice remains normal to patient, and there is no sign of recurrent HPV vascularity or lesion.

Is it long-term remission? (6 of 8)

A slightly blurry narrow band view, again showing no sign of stippling. Is she “cured?” Or in long-term remission?

Recurrent Papilloma (7 of 8)

After 8 years of normal voice, the patient re-presented due to hoarseness, saying that her voice had been “perfect” up until a few weeks earlier. She was not sick, but noticed increased “drainage” and voice change. The explanation is a recurrent papilloma.

Stippled vascularity (8 of 8)

Narrow band light again accentuates the stippled vascularity. The patient is embarking on another “curative mode” series of surgical procedures, hoping to again put her into remission.

Papillomas, HPV Subtype 11, before and After Removal

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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

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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

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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

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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

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Lesions and papillomas of HPV subtype? (1 of 8)

At initial diagnosis, as yet untyped for HPV. Multi-focal lesions on both vocal cords.

Subtle lesion (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).

Open phase (3 of 8)

Strobe light, open phase of vibration, showing mismatch.

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.

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.

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.

After injecting adjuvant (7 of 8)

After both cords have been “inflated” with adjuvant medication. Note the convex, slightly blanched vocal cord margins, due to superficial infiltration of the medication.

After 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

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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

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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

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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

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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

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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

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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

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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

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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, 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

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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

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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.

Months after treatment: no papilloma (5 of 5)

Durable resolution of papilloma, many months afterwards. Compare with photo 1.

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.

Subtle Papillomas, HPV Subtype 6

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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

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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

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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

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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?

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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?

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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

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"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

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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

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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

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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:

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.
Recurrent Respiratory Papillomatosis (RRP) | What Is It?
In this video, Dr. Robert Bastian discusses chronic human papilloma virus (HPV) infection of the larynx (especially vocal cords), causing hoarseness.

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:

Laryngocele

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Laryngocele (1 of 5)

Before phonation begins: the laryngocele is not visible.

Saccule (2 of 5)

Phonation begins: the saccule suddenly begins to inflate.

Saccule blocks airway (3 of 5)

The saccule is at peak inflation. Note how this obstructs the laryngeal airway.

Phonation ending (4 of 5)

The saccule is deflating. Note the motion blur; inflation and deflation each happens in a fraction of a second.

Phonation ended (5 of 5)

The laryngocele is again fully deflated and hidden from view.

Bilateral Laryngocele, Before and After Removal

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Bilateral laryngocele (1 of 8)

Vocal cords approaching point of best closure possible (due to left cord paresis). Faint dotted lines outline the approximate boundary of each laryngeal saccule, which not yet inflated.

Bilateral laryngocele (2 of 8)

As air just begins coming upward between the cords, one can see subtle inflation (dotted lines), particularly of the right saccule (left of image).

Bilateral laryngocele (3 of 8)

As phonation continues, inflation of the (now diagnosable) laryngocele becomes obvious, and the left laryngocele (right of image) is now more obviously inflated than before, again indicated by the dotted lines.

Bilateral laryngocele (4 of 8)

Near the end of a sustained period of voicing, maximum inflation of the laryngoceles is seen (dotted lines). On the right side (left of image), the stretching mucosa is so thinned as to appear translucent.

Bilateral laryngocele, after removal (5 of 8)

Same patient, breathing position, 12 weeks after complete removal of the bilateral laryngoceles via false cord incisions (lines of incision shown by dotted lines). This patient also has long-standing paralysis of the right vocal cord (left of image) and limited mobility of the left cord, so the cords don’t open fully for breathing.

Bilateral laryngocele, after removal (6 of 8)

Phonatory position. Note the lack of inflation of the now-absent laryngoceles, and compare that with photos 3 and 4 of this series.

Bilateral laryngocele, after removal (7 of 8)

Closer view of the posterior ends of the true vocal cords during maximal abduction for breathing. Space between the vocal cords is an estimated 50% of normal, because of the paralyzed right cord and the limited mobility of the left cord.

Bilateral laryngocele, after removal (8 of 8)

Same close-up view, but during phonation. The left vocal cord (right of image) has shifted slightly toward the midline, but the cords do not actually close and, thus, the patient cannot produce glottic (true vocal cord) voice. An implant could help to close this gap, but the patient will first try developing a “false cord voice.”

Laryngocele, Seen in a CT Image

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Laryngocele, seen in a CT image (1 of 1)

The patient’s left-sided saccule is dilated and filled by air, forming a laryngocele (the largest black spot in the image). The right-sided saccule is not seen because it is of normal size. The two smaller black spots show air in the pyriform sinuses (a normal finding).

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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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, before surgery (2 of 3)

Same patient. Narrow-band illumination shows the vascular markings more clearly.

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 (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 (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.

Glottic sulcus (3 of 10)

Closed phase of vibration, but not quite closing completely.

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, just prior to injection (5 of 10)

At the prephonatory instant, under standard light. In addition to a sulcus, this patient has congenital 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 (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 (8 of 10)

The other vocal cord is now being injected.

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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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).

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).
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Glottic sulcus (1 of 2)

Bilateral sulci, more subtle; opening closer to the free margin.

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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Glottic sulcus (1 of 2)

Mucosal bridge / glottic sulcus.

Glottic sulcus (2 of 2)

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

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 (3 of 4)

Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and 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 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).

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.

Glottic sulcus operation (3 of 7)

Rolling the cord laterally with an instrument causes the sulcus to gape open.

Glottic sulcus operation (4 of 7)

A needle is inserted lateral to the still-gaping sulcus to infiltrate for both vasoconstriction and hydrodissection.

Glottic sulcus operation (5 of 7)

The epithelial-lined “pocket” is nearly dissected free from the interior of the cord.

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.

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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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.

Surgical removal of glottic sulcus (2 of 4)

An elliptic incision has been made around the lips of the sulcus.

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.

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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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.

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.

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.

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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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.

Open phase (2 of 4)

Open phase of vibration at the same pitch, showing full-length oscillation.

Closed phase (3 of 4)

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

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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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.

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.

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, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.

Segmental vibration (5 of 6)

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

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 (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 (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 (3 of 4)

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

Lower pitch reveals furrow (4 of 4)

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

Mottled Vocal Cord Mucosa May Hide Glottic Sulci

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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.

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.

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.

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 (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 (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.

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 (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.”

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.

Vocal Cords without Lesion (6 of 6)

The closed phase of vibration. Compare with photo 3.

Nuances of Endotracheal Tube Injury

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

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Maximum glottic opening (1 of 8)

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

Undersurface mucosa indraws (2 of 8)

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

Phonation (3 of 8)

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

Posterior commissure divot (4 of 8)

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

Further evidence of scarring (5 of 8)

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

View into trachea (6 of 8)

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

Vibration of trachea (7 of 8)

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

Open trachea beyond the tube (8 of 8)

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

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


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

Stenosis

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

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


Photos of Stenosis:

Tracheal Stenosis

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Tracheal stenosis (1 of 4)

Panoramic view showing normal larynx but, in the distance, narrowing of the trachea to an estimated 40% of normal diameter. Caused by long-term intubation and tracheotomy injury.

Tracheal stenosis (2 of 4)

View from just below the vocal cords.

Tracheal stenosis (3 of 4)

View at the stenosis showing more clearly its scarred, non-inflamed nature.

Just below the tracheal stenosis (4 of 4)

View of distal trachea after just passing the stenosis. Carina in the distance.

Subglottic Stenosis, before and after Dilation

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Subglottic stenosis, before dilation (1 of 2)

This individual has undergone at least a dozen prior dilations, each of which provides dramatic relief from noisy breathing and exercise intolerance. Here the patient is halfway to needing re-dilation, due to the typical inflammatory stenosis that is seen. Compare with photo 2.

Subglottic stenosis, after dilation (2 of 2)

One week after one of this patient's dilations (with Kenalog injection and topical Mitomycin C), showing a dramatic widening of her airway; compare with photo 1. After a number of years, inflammatory lesions such as this sometimes "burn out," and the interval between dilations increases.

Tracheal Stenosis

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Tracheal stenosis (1 of 3)

Tracheal stenosis due to combination of long-term intubation and tracheotomy. This view is from the level of the vocal cord. Patient has some functional collapse at the membranous tracheo-esophageal party wall (arrow) when she exhales.

Tracheal stenosis (2 of 3)

Closer view, just above the stenosis.

Just below the tracheal stenosis (3 of 3)

After just passing the stenosis, normal trachea seen distally.

Tracheal Stenosis and Collapse

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Tracheal stenosis and collapse (1 of 2)

Due to a life-threatening illness, this person had an endotracheal tube in place for a few weeks. When she got stronger, a tracheotomy tube (not seen as it is below this level of the trachea) was inserted. The result is severe scarring in the trachea. The expected diameter of the tracheal opening is indicated by the dotted line. The “X” marks the same location in each of the two photos.

Tracheal stenosis and collapse (2 of 2)

When this person exhales fully through her tracheotomy tube, or if she attempts to speak, the membranous tracheal wall also bulges forward, and obliterates the tiny residual opening. Dilation has been performed but helped minimally. The indicated procedure, if her severe medical condition will allow, is removal of the damaged segment of the trachea with reconstruction (aka tracheal resection, primary reanastomosis).

Tracheal Stenosis, Due to Forme Fruste Wegener’s Granulomatosis

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Tracheal stenosis (1 of 3)

View from level of vocal cords shows residual lumen of airway at only ~35% of normal. The dotted circle shows how big the lumen should be.

Tracheal stenosis (2 of 3)

Closer view shows the characteristic appearance of mucosa and the inflammatory nature of the stenosis (pinkness).

Just below the tracheal stenosis (3 of 3)

After just passing through the stenotic area, distal trachea is normal in caliber and color.

Subglottic / Tracheal Stenosis

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Wegener's granulomatosis (1 of 4)

Inflammatory subglottic/tracheal stenosis, thought to be the result of an incomplete expression of Wegener's granulomatosis (no history of trauma).

Subglottic / Tracheal stenosis (2 of 4)

Close view, from vocal cord level.

Subglottic / Tracheal stenosis (3 of 4)

Close view, from just above vocal cords.

Inflammed Stenosis (4 of 4)

Close view, showing the inflammatory nature of the stenosis.

Hypopharyngeal Stenosis

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Hypopharyngeal stenosis: not yet visible (1 of 2)

Panoramic view of the larynx, with the swallowing “crescent” in the middle of the view (indicated by the dotted lines). Several months prior, this patient had laser resection for hypopharyngeal cancer. Expected scarring from the surgery led to a stenosis (that is, a narrowing) at the entrance to the esophagus. The stenosis cannot be seen here, but is revealed in the next photo (for reference, an “X” marks the same point in the larynx in both photos).

Hypopharyngeal stenosis: revealed (2 of 2)

The patient performs the trumpet maneuver, which splays open the hypopharynx, revealing the stenosis; the dotted lines represent what would be a normal-sized opening. 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.

Subglottic Stenosis, Due to Wegener’s Granulomatosis

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Subglottic stenosis, due to Wegener's (1 of 2)

This person has Wegener’s granulomatosis, confirmed by anti-neutrophil cytoplasmic antibodies (ANCA) testing. Here, looking from above the vocal cords, one can see an estimated 50% narrowing of the subglottic and high tracheal passageway.

Subglottic stenosis, due to Wegener's (2 of 2)

Viewed from within the subglottis, one can see more clearly the inflammatory nature of this stenosis. A dotted oval estimates what the normal caliber or width of this airway would be. This patient has been managed with systemic medication, but also occasional dilation, steroid injection, and Mitomycin C application.

Subglottic Stenosis, before and after Dilation

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Subglottic stenosis (1 of 5)

Middle-aged woman with unexplained shortness of breath and noisy breathing, due to this idiopathic inflammatory and very high subglottic stenosis. The patient initially declined dilation due to her anxiety. She also had granularity of the nasal septum and a positive ANCA profile for Wegener’s granulomatosis.

Subglottic stenosis, worsened (2 of 5)

Five months later, the symptoms became intolerable, and the stenosis was noted to be slightly narrower and with a greater posterior component. The patient agreed to dilation.

Subglottic stenosis, worsened (3 of 5)

Same exam as photo 2; this close-up view shows more clearly the inflammatory nature of this stenosis.

Subglottic stenosis, after dilation (4 of 5)

Five days after outpatient dilation, triamcinolone injection, and topical mitomycin C application. The patient’s symptoms have vanished, the harsh inspiratory noise is no longer heard, and the size of the airway, though still not normal, is more than doubled. Compare with photo 2 of this series.

Subglottic stenosis, after dilation (5 of 5)

Same exam as photo 4, close-up view. Intensification of the inflammatory changes of this stenosis are expected so early after dilation. Compare size of the stenosis with photo 3 of this series.

Airway Stenosis Caused By Wegener’s Granulomatosis, Before and After Dilations

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Airway stenosis (1 of 5)

Marked inflammatory narrowing in the immediate subglottis. Within the ring of arrows is the inflamed, reddened tissue, which is narrowing the airway into the shape of a slit. This man needs to be active for his work, but notices shortness of breath and noisy breathing with exertion.

Airway stenosis, after dilation (2 of 5)

Nine days after a dilation procedure, with local steroid injection and painting with Mitomycin C. The airway has widened, so that it is more oval-shaped and less slit-like. Compare with photo 1. Although a degree of stenosis remains, symptoms have subsided dramatically. For reference, asterisks mark the same points in the subglottis in this photo and the next photo.

Airway stenosis, after dilation (3 of 5)

Same exam, looking beyond the immediate subglottis. There is an inflammatory response that involves several centimeters of the upper trachea. Inflammatory areas often “trap” mucus, as seen here.

Airway stenosis, before another dilation (4 of 5)

Now five months after the dilation procedure mentioned in photos 2 and 3. The patient has been receiving systemic treatment with methotrexate and prednisone. General appearance of the inflammation has decreased. In spite of this, as expected, the stenosis has persisted (dotted oval shows the estimated caliber or width of a normal airway) and symptoms have gradually increased. Thus, another dilation was scheduled for the next day.

Airway stenosis, after another dilation (5 of 5)

A week after photo 4, following the most recent dilation. There is expected immediate postoperative inflammation and an increase in the airway’s caliber or width by an estimated 30% (dotted oval again shows the estimated caliber or width of a normal airway; compare with photo 4). Symptoms are again abolished.

Tracheal Stenosis, before and after Tracheal Resection and Primary Reanastomosis

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Tracheal stenosis (1 of 8)

This view from the level of the vocal cords shows high-grade tracheal stenosis, involving rings two, three, and four; the airway here is an estimated 30% of its normal diameter. For reference, a dotted line marks the level of the cricoid cartilage.

Tracheal stenosis (2 of 8)

Slightly closer view. This patient is very short of breath with minimal activity and, even at rest, has audible stridor. Elsewhere, across a span of several prior weeks, she had undergone three dilation procedures with only minimal, transient benefit.

Close up view (3 of 8)

Close-up view shows scarring, collapse of tracheal walls, and some granulation tissue.

Just below the tracheal stenosis (4 of 8)

The trachea just beyond the stenosis is normal.

Tracheal stenosis, 5 days after surgery (5 of 8)

Five days after tracheal resection and primary reanastomosis. Compare with photo 1. Note that the airway’s diameter has at least tripled (part of the opening is obscured by tenacious mucus). The patient’s shortness of breath is now gone, as is the stridor.

Tracheal stenosis, 5 days after surgery (6 of 8)

Close-up of the line of anastomosis, with a couple of sutures visible. Compare with photo 3. Again, tenacious mucus in the upper part of the photo is obscuring part of the view.

Tracheal stenosis, 2 months after surgery (7 of 8)

Another eight weeks later. The airway is wide-open and has also now healed since the surgery. Compare this view with photo 1 (pre-surgery) and photo 5 (early follow-up).

Tracheal stenosis, 2 months after surgery (8 of 8)

Compare this view with photo 2.

Dilation for Post-Radiation Hypopharyngeal Stenosis

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Dilation for post-radiation hypopharyngeal stenosis (1 of 4)

Early after radiotherapy for left vocal cord cancer (indicated by arrow), tumor seems to have responded, but it has become difficult to swallow solid foods due to a radiation-induced stricture (indicated by solid oval) with expected lumen (indicated by the dotted lines).

Dilation for post-radiation hypopharyngeal stenosis (2 of 4)

Closer-range view of the stricture at opening to the esophagus.

Dilation for post-radiation hypopharyngeal stenosis (3 of 4)

A tapered device used for dilation (bougie) is now inserted into the stricture and down into the upper esophagus in order to enlarge the entrance to the esophagus.

Dilation for post-radiation hypopharyngeal stenosis (4 of 4)

Immediately following dilation, the opening is enlarged (compare with photo 2). The patient’s ability to swallow food improved noticeably, but not to normal.

Tracheal Deformity and Stenosis, before and after Repair

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Upper tracheal stenosis, before repair (1 of 6)

View from above the level of the vocal cords, showing severe narrowing and deformity of the upper trachea, caused by a “difficult” tracheotomy many years earlier. This man is frustrated by activity limitations, and difficulty coughing up accumulated mucus.

Upper tracheal stenosis, before repair (2 of 6)

View from just below the level of the vocal cords, showing the deformity and stenosis more clearly.

Looking from below the stenosis (3 of 6)

The trachea below the area of stenosis is normal.

After tracheal repair (4 of 6)

View from just above the level of the vocal cords, six weeks after tracheal resection and primary anastomosis, showing final result. Patient feels he breathes completely normally. Compare with photo 1.

After tracheal repair (5 of 6)

View from just below the level of the vocal cords. The tracheal caliber is now virtually normal. A broken, absorbable suture is seen at 2 o’clock, and a tiny remaining unhealed area is at 11 o'clock. Compare with photo 2.

After tracheal repair (6 of 6)

A close-up view shows the circular line of the anastomosis more clearly.

Post-Intubation Stenosis

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Endotrachel tube injury (1 of 4)

View of larynx of an individual in critical condition who was ventilated for 2 weeks via an endotracheal tube. See the erosion of the posterior right cord (left of photo) from pressure necrosis of the endotracheal tube, indicated by the white, semi-circle markings.

Closer view, between the posterior vocal cords (2 of 4)

With tip of endoscope positioned deeper within the larynx, between the posterior vocal cords, a small opening is visible several centimeters distally. Diameter of the opening is an estimated 20% of normal, which is below the level of the patient's tolerance, and explains why a (white) tracheotomy tube has been placed.

Even closer view, showing upper surface of the tube (3 of 4)

Closer view, showing more clearly the curved upper surface of the tracheotomy tube entering just below the stenosis and serving as a “back door” for breathing.

Non-inflammatory stenosis, caused purely by injury (4 of 4)

Note in this close-range view that this is a non-inflamed kind of stenosis caused purely by injury. Compare this with stenosis from presumed forme fruste Wegener’s granulomatosis.

Sickle Cell Disease and Laryngeal Stenosis

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Sickle cell disease and subglottic swelling (1 of 4)

Distant view of vocal cords and immediate subglottic swelling in a man in early 30’s with sickle cell disease (SCD). During a SCD crisis, he was intubated for approximately 10 days, and then due to inability to extubate, a tracheotomy was performed

At closer range (2 of 4)

At closer range, the dotted line again indicates the margin of the true cords. Is this stenosis a complication of intubation only, or was the endotracheal tube injury exacerbated by sickling/ hypoxia in the area?

Maturing granuloma (3 of 4)

The greatest point of narrowing is estimated to be only 30% of normal lumen size. Some of that space is taken by a maturing granuloma (G).

High-grade stenosis ( 4 of 4)

A view from within this high-grade stenosis shows no additional stenosis at the level of tracheotomy tube entry.

Subglottic Granulation and Curving Airstream

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Intubation injury (1 of 4)

After a 9-day intubation for serious illness, the patient has difficulty breathing due to this “proud flesh” response to injury within the cricoid ring, posteriorly. Breathing has improved in the past week, leading to a decision to await further maturation, rather than proceeding to microlaryngoscopic removal.

Lobules (2 of 4)

Close-up view of the lobules of granulation tissue. Air can easily pass around the obstruction as indicated by the arrows.