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

 

 

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

TEST I: “HAPPY BIRTHDAY”

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

TEST II: STACCATO

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

COMMON QUESTIONS

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

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

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

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

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

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

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

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

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

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

Do I need to cancel everything until the ceiling recovers?

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

Are there common pitfalls in use of the swelling tests?

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

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

Open Epidermoid Cyst

An open epidermoid cyst occurs when it spontaneously ruptures, but yet not empty all of its contents (keratin). The outline of the partially-emptied cyst may still be very evident, but it usually assumes an oval shape with the long axis oriented anteriorly and posteriorly. If the cyst empties nearly completely, the white oval is no longer seen, but the vocal cord may have a mottled appearance. If the cyst empties completely, a sulcus lined by epithelium remains.


Photos:

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.

Possible Open Epidermoid Cyst

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Capillary ectasia and white submucosal abnormality (1 of 3)

Left vocal cord (right of photo) has not only overlying capillary ectasia, but a white submucosal abnormality.

Prephonatory view, mtd (2 of 3)

Prephonatory instant shows some muscular tension dysphonia as well.

Open cyst (3 of 3)

Closer view. While an intact epidermoid cyst has a distinct outline, an open cyst develops a more mottled appearance. It may leak intermittently from a tiny dimple or sulcus which is sometimes seen at very close range.

Open Cyst and Sulcus in Same Patient

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Hoarse voice (1 of 4)

A young woman with a history of repeated loud cheering during athletic activities, to the point of hoarseness. She has a sulcus of the right cord (left of photo), and an open cyst of the left ( right of photo). Openings from sulcus and cyst are indicated by dotted lines.

Cyst + sulcus (2 of 4)

Narrow band light. The lateral lip of a sulcus is often bordered by a prominent capillary as seen here. An open cyst assumes an elliptical shape in the anteroposterior direction. It fails to empty completely because the opening draining it is smaller than the diameter of the cyst.

Closed phase (3 of 4)

Closed phase of vibration, strobe light.

Open phase (4 of 4)

Open phase of vibration.

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.

Open Epidermoid Cyst-Sulcus

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Chronic hoarseness (1 of 4)

This woman suffers from chronic hoarseness. Note the relatively normal left vocal cord (right of photo) but that the right side has a whitish lesion at the margin. Equally important is the faint white submucosal collection of keratin indicated by dotted line.

Cyst under narrow band light (2 of 4)

Under narrow band light, the arrow indicates the sulcus opening that allows what was likely an epidermoid cyst to partially empty.

Closed phase (3 of 4)

Under strobe light, closed phase also shows a slight “divot” at the opening into the presumed collapsed cyst.

Open phase (4 of 4)

Open phase, showing that the amplitude of vibration (flexibility) of the affected side is understandably less than on the opposite (left) side.

Indicator Lesions

Indicator lesions are visual findings of vibratory injury in a person who has no current voice complaints, and whose “swelling checks” are normal.

Background:

Individuals who fit the “vocal overdoer profile” may only notice vocal limitations caused by vibratory injury on an occasional and transient basis. These episodes may be brushed off as insignificant, because they are so brief, and recovery so complete. Even while asymptomatic, however, such individuals may have subtle visual findings of vibratory injury—“Indicator lesions.” Unless discovered during a screening examination for entry to music studies, the individual may be unaware of these findings. What if indicator lesions are found? Suggested responses:

1. Make sure the individual understands that these are indicator lesions and as such constitute a “yellow flag” suggesting at least occasional overuse of voice.

2. Define the “vocal overdoer syndrome” for the person as the combination of and interaction between an expressive, talkative, extroverted personality and a “vocally busy” life. Said another way, there may be both intrinsic, personality-based and extrinsic, vocal commitment based reasons that amount and forcefulness of voice may be excessive. A 7-point talkativeness scale can be used to estimate the intrinsic risk, where “1” represents Clint Eastwood, “4” the averagely talkative person, and “7” the life of the party. The extrinsic risk is addressed by making a list of vocal commitments such as for occupation, childcare, hobbies, social activities, religious practice, athletics/ sports, and rehearsal and performance.

3. Discuss the symptom complex of mucosal injury:

a) Loss/ impairment of high, pianissimo singing;

b) Day-to-day variability of vocal clarity and capability;

c) A sense of increased effort to produce voice;

d) Reduced mucosal endurance, or becoming “tired” vocally from amount/ manner of voice use that does not seem to induce this in others;

e) Phonatory onset delays—the slight hiss of air that precedes the beginning of the sound, especially if high and soft. Speaking voice hoarseness can be a fairly late and gross symptom of mucosal injury.

4. Talk about managing the amount, manner, and spacing of voice use to reduce unnecessary wear and tear on the vocal cord mucosa.

5. Teach vocal cord swelling checks as a means of detecting even subtle injury. Respond to what they tell you!

Singers are understandably distressed when they discover even the tiniest mucosal swelling such as indicator lesions. That is because for true singers, singing is not just what they do; the term “singer” also defines who they are. So injury threatens both activity and identity. Consequently, discuss indicator lesions with great care and sensitivity. Keep in mind that some doctors speak of “small vocal nodules that do not interfere with singing.”

Small nodules that are but a tiny step above indicator lesions, especially when spicule-shaped rather than fusiform, always exact a penalty to the singing voice (see #3 above), but limitations can often be concealed by warming up, and singing more loudly. Singers often say “I have a big voice that doesn’t do pianissimo.” That is, pp becomes p; mp becomes p; mf becomes f; and so forth. Alternatively, the singer considers the missing pianissimo to be a technical fault.


Indicator Lesions and MTD

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Breathy voice (1 of 6)

Distant view at the prephonatory instant in young female singer. There is a wide gap between the cords. The explanation for this gap is not immediately evident, but the voice is breathy.

Phonation (2 of 6)

Phonation has started with margin blurring, and the sense of extra space between the cords remains.

Open phase (3 of 6)

Strobe light, open phase of vibration at B4 (494 Hz)

Closed phase (4 of 6)

Closed phase of vibration, still at B4. Note the incomplete closure posteriorly caused by MTD. Arrows indicate the vocal processes.

Open phase, indicator lesions (5 of 6)

Open phase of vibration, strobe light, at F#5 (740 Hz). Here, the subtle indicator lesions are seen more clearly; vocal cord margins are not perfectly straight.

"Closed" phase, MTD (6 of 6)

“Closed” phase of vibration is not really closed and the vocal processes do not come into full closure, again consistent with MTD.

Indicator Lesions

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Middle-aged teacher (1 of 4)

Middle-aged teacher who also sings. She is aware of effortfulness to sing; this is hard to interpret because she is pre-menopausal and also not actively singing/ grooming her voice. Extraordinarily subtle margin swellings could easily be overlooked in this view.

Phonatory view (2 of 4)

During phonation at E-flat 4 (311 Hz) with vibratory blurring under standard light. The subtle narrowing of the blurred dark line between the folds could still be overlooked.

Pre-phonatory instant (3 of 4)

Use of the pre-phonatory instant by having the patient do repeated staccato at the same pitch. Here, very small, low-profile, and broad-based swellings can be seen.

Indicator swellings (4 of 4)

At much higher pitch, E5 (659 Hz) and using strobe light. In this view of the open phase of vibration, at high magnification, the rounded “indicator swellings” are seen best.

Submucosal Fibrosis

Submucosal fibrosis is a disorder in which the attachment of the mucosa to the underlying vocal ligament appears to thicken and toughen, yet without creating any protrusion, such as one sees with nodules or polyps. The mucosa thereby becomes less flexible. Think of satin turning into canvas of a similar thickness.


Surgery for Fibrosis, Polyp

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Fibrosis + polyp (1 of 4)

An intense and dynamic teacher (not a singer) has developed not only polyp/ elevation, but fibrosis--the white submucosal deposition of scar-like tissue deposits. Narrow band illumination makes the nature of these lesions more "emphatic."

Strobe light (2 of 4)

Under strobe light during voicing. Poor match and stiffness are best seen.

Post microsurgery, open phase (3 of 4)

A week after vocal cord microsurgery, voice is markedly improved. No attempt was made to remove all of the fibrosis, but only to straighten the vocal cord margins. Open phase of vibration at F5.

Post microsurgery, open phase (4 of 4)

Closed phase of vibration at same pitch shows that some margin swelling remains. The patient also has MTD; posterior cords are widely separated.

Submucosal Fibrosis

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Submucosal fibrosis (1 of 4)

Under standard light. Note the whitish appearance that is visible through the mucosa.

Submucosal fibrosis (2 of 4)

Under narrow-band light.

Submucosal fibrosis (3 of 4)

Under strobe light, closed phase of vibration. Shows imperfect match but no obvious protrusion.

Submucosal fibrosis (4 of 4)

Under strobe light, open phase of vibration. Amplitude of vibration (distance of vibratory separation) not as great as would be expected in a normal larynx; this is due to the stiffening effect of fibrosis.

Fibrosis as a Base to Nodules, Before and After Surgery

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Bilateral polypoid nodules (1 of 8)

Fibrosis as a Base to Nodules, Before and After Surgery

Narrow-band lighting (2 of 8)

At greater magnification, and also under narrow-band light. The area of fibrosis is more clearly seen, now without the dotted lines.

Closed phase (3 of 8)

Closed phase of vibration at ~A4 (440 Hz), as seen under strobe light.

Open phase (4 of 8)

Open phase of vibration also at ~ A4.

Two weeks after surgery (5 of 8)

Less than two weeks after surgical removal of the polyps. The faint white zone of margin fibrosis is again seen. Compare with photo 1.

Phonation (6 of 8)

Phonation under standard light shows that vocal cord margins now match, and both margins blur; suggesting vibratory flexibility.

Margin fibrosis (7 of 8)

Closed phase of vibration, at ~ A4 (440 Hz), as seen under strobe light. Margin fibrosis seen best here, indicated by the black dotted line. Compare with photo 3.

Open phase (8 of 8)

Open phase of vibration. The same pitch (A4) reveals excellent vibratory flexibility and equal amplitude (lateral excursion) of vibration. Compare with photo 4.

Submucosal Fibrosis, not Leukoplakia or Candida

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Submucosal fibrosis (1 of 3)

Middle-aged man who works in sales and also uses voice aggressively during regular athletic activity. Voice is raspy and variable. Note here "plaques" of white material that appear to be submucosal and extend beyond the obvious areas (dotted lines). No erythematous "surround" such as would be seen with candida.

Closed phase (2 of 3)

Closed phase vibration, strobe light at F4, again showing submucosal fibrosis.

Open phase (3 of 3)

Open phase of vibration, also at F4.

An Extreme Example of Protective Fibrosis Deposits

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Extroverted elementary teacher (1 of 6)

Elementary teacher and major extrovert is grossly hoarse. Here you can see the fibrotic-appearing injuries bilaterally and an extra translucent polypoid component on the left cord (right of photo).

Submucosal fibrosis (2 of 6)

Under narrow band light, the white area is not hazy leukoplakia, but instead submucosal fibrosis, deposited as a protection against mucosal vibratory collision/ shearing injury.

Phonatory view (3 of 6)

Under strobe light, closure is imperfect due to the mid-cord elevations.

Open phase (4 of 6)

Open phase of vibration with small amplitude and absent “mucosal wave” due to stiffness of the mucosa.

Post microsurgery, open phase (5 of 6)

A week after vocal cord microsurgery, voice is markedly improved. No attempt was made to remove all of the fibrosis, but only to straighten the vocal cord margins. Open phase of vibration at F5.

Post microsurgery, closed phase (6 of 6)

Closed phase of vibration at same pitch shows that some margin swelling remains. The patient also has MTD; posterior cords are widely separated.

Anterior Saccular Cyst

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Anterior saccular cyst (1 of 4)

Breathing position, with a saccular cyst protruding from the right anterior ventricle (left of image). The cyst’s location, color, and superficial vessels indicate that it is neither a polyp nor granuloma.

Closer view (2 of 4)

Still closer view (under strobe light), breathing position, showing that the cyst does not arise from the cord, but appears to be depressing the anterior end of the right cord (left of image) slightly. On the left cord is an incidental finding of margin swelling, which is unsurprising in this very talkative individual.

Cyst vibrates when speaking (3 of 4)

Phonation, strobe light, open phase of vibration. The laryngeal vestibule between the false cords is partially blocked. The cyst occasionally participates in vibration, making an extra sound.

Anterior saccular cyst (4 of 4)

Phonation, strobe light, closed phase of vibration.

Glottic Furrow

A disorder in which a furrow or groove is seen on the vocal cord, running parallel to, and at or just below, the cord’s free margin. This glottic furrow normally represents a defect in the underlying vocal ligament. Often, the deepest part of the furrow is lined with epithelium that is attached directly to thinned vocal ligament. Pseudobowing (due to mucosal and ligament abnormality more than atrophic muscle) is also a common feature.

Glottic furrow vs. glottic sulcus

A furrow is to be distinguished from a sulcus, which is more a defect within the mucosal layer only, and is thought to represent the empty sac of what was formerly a cyst. A furrow is typically shallow, and its lips are apart; a sulcus is usually deeper, and its lips are in contact and therefore harder to see. A furrow normally adheres to the vocal ligament, and the apex or deep surface of a sulcus often does as well. However, in the case of a sulcus, the vocal ligament itself is normal. Also, in the case of a furrow, the mucosal layer—often only an epithelial layer, in fact—will tend to adhere more broadly to the ligament, due to loss of the Reinke’s space layer of the mucosa.


Photos:

Glottic Furrow

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Glottic furrow (1 of 4)

Congenital furrows, on both vocal cords, in a 14-year-old with lifelong husky, air-wasting voice. Seen here at a distance, under standard light, with cords in breathing position. The margin of each cord, especially that of the left cord (right of photo), has a "flattened" appearance.

Glottic furrow (2 of 4)

As the cords come nearly to phonatory position, notice the pseudo-bowing, and persistence of flattening or even "farmer's field" furrow.

Glottic furrow (3 of 4)

Phonation, open phase of vibration, under strobe light, shows large amplitude (lateral or outward excursions) and, at each line of arrows, an "edge" of mucosa. This edge is seen because the mucosa of the broad expanse of the free margin is closely adherent and cannot oscillate.

Glottic furrow (4 of 4)

At this patient’s most closed phase of vibration, under strobe light. Note that the leading edge of non-adherent vocal cord mucosa (again indicated by arrows) has slid medially (compare with photo 3).

Glottic Furrow / Leukoplakia / Acid Reflux

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Glottic furrow / Leukoplakia / Acid reflux (1 of 4)

Panoramic view, standard light. Note general inflammatory appearance, left vocal cord leukoplakia, interarytenoid pachyderma. Some would call this a sulcus.

leukoplakia (2 of 4)

Furrow-like groove best seen on the left vocal cord (arrow). Beneath the arrow is the leukoplakia. Notice loss of fine surface vessels in this area.

Glottic furrows (3 of 4)

Furrows seen bilaterally.

Gap during closed phase (4 of 4)

Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

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 Furrow, Showing Adherent Furrow Muscoa

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Glottic furrow, showing adherent furrow muscoa (1 of 4)

Standard light showing partially abducted cords. Here, the furrow on the right cord (left of photo) is seen best.

bilateral glottic furrows (2 of 4)

Closer view, now showing the bilateral glottic furrows more clearly (indicated by the dotted lines).

medial oscillatory position (3 of 4)

Under strobe light, closed phase of vibration. Focus on the right cord (left of photo), and note that the dotted line shows medial oscillatory position of mobile mucosa. The small elevation indicated by the large dot is a reference for comparison with next photo.

Mucosal Wave (4 of 4)

Open phase of vibration. The mucosal wave is very far lateral on the upper surface of the vocal cord, indicated now by the curved dotted line. The small elevation has barely lateralized, consistent with the adherent stiff mucosa of the furrow itself.

Glottic Furrow—A Thinning of Reinke’s Space

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Glottic furrow (1 of 4)

This man has performed intense popular music for many years, and has developed loss of strength and clarity of voice. Here, the tiny dots outline bilateral glottic furrows, where the epithelium is more closely adherent to the vocal ligament than it is elsewhere.

Strobe light (2 of 4)

This view under strobe light shows the right-sided furrow enclosed by tiny dots.

High pitch (3 of 4)

At very high pitch under strobe light, vocal cord margins match well; the cause of this man's hoarseness is not a typical vibratory injury such as nodules or a polyp.

Thinning of Reinke's space (4 of 4)

Open phase of vibration, with only the lateral edge of the furrows marked with a dotted line. Part of the stretchy "cushion" of Reinke's space is lost and with it the mechanical de-coupling of mucosa from vocal ligament beneath.

Double Whammy: Intubation Injury + Glottic Furrows

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Intubation injury + glottic furrows (1 of 4)

Extremely poor voice in elderly man after severe, life-threatening illness with complications; including an 18-day endotracheal intubation for purposes of ventilation. Now he is being evaluated for his very poor voice. Here, open (breathing) position at a distance does not show the findings as clearly as in subsequent photos. Small X's are for reference with remaining photos. The arrows denote tip of vocal processes.

Bilateral glottic furrows (2 of 4)

At closer range, divots begin to be appreciated (above the X's) and bilateral glottic furrows are more clearly noted.

Intubation injury (3 of 4)

As the vocal cords begin to close, this view (deep into the posterior commissure) shows clearly the divots caused by pressure necrosis outline where the breathing tube sat. Dotted lines show what would be the normal line of posterior vocal cords.

Phonatory position (4 of 4)

Now in closed voice-making position, posterior defect is out of view, but the vocal processes remain visible and come into contact at arrows. This shows that the endotracheal tube injuries are divots only without scarring of the joint capsules (that if present would prohibit contact of the vocal processes at arrows). There is air wasting through the posterior keyhole not visible here, and the bilateral glottic furrows and pseudo-bowing are extremely evident. They cause additional air-wasting, and adherence of mucosa at the depth of the furrows interferes with the mucosa’s vibratory ability.

Furrow Causing Chronically Husky Voice After Years of Extensive and Often Intense Voice Use

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Huskiness (1 of 4)

Huskiness in the context of the series title. Subtle "depressions" in the area outlined become more obvious in the following photos.

Pre-phonatory view (2 of 4)

As the vocal cords come slightly towards each other in preparation to make voice, the depressions are a little more evident.

Depressed area (3 of 4)

Here the depressed area is best seen at low pitch.

High pitch (4 of 4)

At high pitch, the depression elongates and becomes shallower.

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.

Glottic Furrow—Not Sulcus

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A rough and fuzzy voice (1 of 6)

This middle-aged woman describes a fuzzy and rough voice quality with fading of strength and endurance across a typical day's use. A part of the explanation is seen here: an obvious furrow of the left vocal cord (arrow, right of photo). Glottic furrows are usually congenital defects involving thinning of the vocal ligament and application of epithelium (mucosa) directly to the ligament with little if any "Reinke's space" (superficial layer of lamina propria).

Furrow (2 of 6)

Narrow band light makes the furrow more evident.

asymmetrical vibration (3 of 6)

Partially open phase of vibration, seen at F4 (349.23Hz) under strobe light reveals the issue of asymmetrical vibration and phase shifting that often correlates with rough quality.

Closed phase ( 4 of 6)

Closed phase of vibration, with the furrow still very visible.

vibration points amplify (5 of 6)

At lower pitch (approximately G3 (196.0Hz), very large amplitude of vibration points out the flaccidity of the vocal cords, and the furrow at the arrow.

Furrow (6 of 6)

At closed phase of vibration still under strobe light, the furrow is seen again more clearly.

Vocal Cord Bruising

The rupture of one or more capillaries in the vocal cords, so that blood leaks into the tissue. This vocal cord bruising occurs as a result of excessively vigorous mucosal oscillation, usually during extensive or vigorous voice use, aggressive coughing, or even a very loud sneeze, and it can make the voice hoarse or otherwise limited.

If the ruptured capillary is extremely superficial, like the capillaries seen on the white of the eye, then a “thin suffusion” kind of bruise occurs, and there is no deformity of the vocal cord margin; within a few days, the voice recovers. If the vessel is a few cell layers deeper into the cord, then a small “puddle” of blood like a micro-hematoma may collect and create a kind of “blood blister.” Although a superficial bruise resolves quickly and doesn’t seem to cause permanent damage, the “blood blister” type can become a hemorrhagic polyp and require surgery; with state-of-the-art surgery, however, the voice can virtually always be restored to its original capabilities.


Photos:

Vocal Cord Bruise / Hemorrhage, Before and After Rest and Surgery

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Vocal cord bruise / hemorrhage (1 of 4)

Bruise, right vocal cord (left of image), estimated one week old, in combination with large polypoid vocal nodules. Note the yellowish discoloration, indicating partial breakdown of the hemoglobin (source of red color of blood) into hemosiderin as bruise is beginning to be cleared away.

Vocal cord bruise / hemorrhage (2 of 4)

Same patient, during phonation.

Vocal cord bruise / hemorrhage, after rest and surgery (3 of 4)

Bruise was allowed to resolve, and then patient underwent vocal cord microsurgery one week prior to this examination.

Vocal cord bruise / hemorrhage, after rest and surgery (4 of 4)

Same patient, during phonation. Note the patient’s tendency to phonate with a gap between the cords, as though the vocal cords “remember” the early contact that used to require separation during voicing. This gap can be lessened through expert speech (voice) therapy.

Vocal Cord Bruise / Hemorrhage

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Vocal cord bruise / hemorrhage (1 of 2)

Bruise, left vocal cord (right of image), estimated three weeks old, in combination with vocal nodules, capillary ectasia. There is likely an ectatic capillary also on the same side, within the nodule, that is the source of the leaking of blood into the tissues. When the bruise first occurred, it would have been most evident in the area of the nodule. As time passes, the central part of the bruise typically resolves first, with the last area to disappear anterior and posterior, as shown here. Note also the faint yellowish discoloration of the left cord, indicating residual hemosiderin (breakdown products of blood in tissue).

Vocal cord bruise / hemorrhage (2 of 2)

Same patient during phonation under standard light.

Vocal Cord Bruise / Hemorrhage, Before and After Rest

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Vocal cord bruise / hemorrhage (1 of 6)

Breathing position, standard light. Notice a superficial bruise of the left cord (right of image), still very bright red. The source vessel cannot be identified with certainty here, but would be expected to be in the mid-cord, where the bruising is least evident. This is because mucosal oscillation tends to "massage" the bruise anteriorly and posteriorly, when the bruise is a thin-suffusion "wet pavement" type rather than a pocket or "puddle" of blood.

Vocal cord bruise / hemorrhage (2 of 6)

Prephonatory instant, standard light, shows that the margin of the left cord (right of image) is relatively straight. This suggests that the bruising is a very thin layer, and not a pocket of blood (as mentioned in photo 1).

Vocal cord bruise / hemorrhage (3 of 6)

Closer phonatory view, strobe light, also shows subtle elevation of the right cord (left of image), and a tiny ectatic capillary (small arrow), both of which can suggest that this person has been using the voice a lot. Left cord shows a darker linear bruise (larger arrow). After the bruising clears, perhaps it will become evident that this is in fact the ectatic capillary.

Vocal cord bruise / hemorrhage: after 2 weeks of rest (4 of 6)

After two weeks of relative voice rest, standard light. Notice the yellowish discoloration, which represents the breakdown products of hemoglobin. No obvious culprit capillary is seen. The last blood to resorb is always at the periphery from the point of origin.

After 2 weeks of rest (5 of 6)

Strobe light, open phase of vibration. No obvious ectatic vessel is seen, except for the vessel on the non-bruised side (at arrow) that was seen in photo 3.

After 2 weeks of rest (6 of 6)

Strobe light, closed phase, shows small margin swellings, greater on the left cord (right of image) than on the right cord. This swelling is being addressed by ongoing mild voice conservation, “on the fly” – i.e., while the person carries on with her work.

Bruise Caused by Cough

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Bruise caused by violent coughing (1 of 2)

Closer view of bruise, with small collection of white mucus in the middle.

Closer view of bruise (2 of 2)

A person with violent sensory neuropathic coughing may injure the vocal cords, as illustrated by this bruise, right vocal cord (left of photo).

Bruising from Sensory Neuropathic Cough

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Bruising from SNC (1 of 1)

This individual occasionally coughs to the point of hoarseness. Particularly noteworthy is the subglottic bruise (arrow, dotted line) caused by profound Valsalva-retching kind of coughing. The rest of the right cord (left of photo) is also bruised.

Vocal Cord Bruising From Coughing

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Bruise from coughing (1 of 3)

This man had an episode of aggressive coughing a week earlier. Note the bruising over the vocal processes, which receive the major collisional force during coughing.

Pre-phonatory instant (2 of 3)

The vocal processes are approaching the point of touching (contact would occur gently with onset of talking and more aggressively with coughing).

Phonation (3 of 3)

Vocal cords are now in full contact. Note the unrelated moderately-severe vocal cord bowing.

The Evolution of Vocal Cord Bruising and Emergence of a Vulnerable Capillary

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Margin swelling and bruising (1 of 2)

This professional woman is extraordinarily dynamic and intense, and must talk all day to do her work. Here, the right vocal cord (left of photo) is bruised due to vibratory trauma. The margin swelling on the right causes her hoarseness more than the bruising, however.

Six weeks later (2 of 2)

Six weeks later, the bruise is mostly resolved. The capillary that “leaked” blood to form the bruise is now seen more clearly (long arrow). This ectatic capillary can be seen easily now when looking back at photo 1. The short arrows indicate the residual “smudges” of discoloration caused by breakdown products of the bruise. The last evidence of widespread vocal cord bruising is always in these two locations.

Videos:

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.

Mucosal Edema or Swelling

Mucosal edema or swelling is the build-up of edema (tissue fluid) within the mucosa, the layer of tissue that lines the body’s interior. In the larynx, this build-up of edema usually occurs at the mid-point of the vocal cords, as the body’s response to vocal overuse, and it resembles a small, low-profile blister.

Vocal overuse triggers this build-up of edema because, with vocal overuse, the vocal cords undergo more vibratory stress and trauma than they are designed to handle. The body responds by gathering edema to form a protective cushion. However, this swelling distorts the vocal cord’s shape and can limit its flexibility, which can thereby impair the voice, making it sound acutely husky or hoarse.

From mucosal edema to nodules:

If the voice is rested even moderately, this edema fluid will disperse rapidly—within 12 to 24 hours if not severe—so that the swelling vanishes and the voice returns to normal. However, if the voice continues to be overused, then the body may build up more chronic swelling materials (no longer just edema), so that the vocal cords develop nodules.


Photos:

Swelling

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Swelling (1 of 4)

Semi-abducted position, standard light.

Swelling (2 of 4)

Pre-phonatory instant. Standard light shows only the suggestion of margin swelling, as the dark space between the cords is not exactly the same along its length

Swelling (3 of 4)

Open phase of vibration. Strobe light shows both wide excursions (indicating mild flaccidity) and margin swellings.

Swelling (4 of 4)

Closed phase of vibration, strobe light. Shows margin swellings more clearly.

Indicator Swellings

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Pre-phonatory (1 of 4)

Pre-phonatory instant at E-flat 5 (622 Hz), conventional view with standard illumination shows no evident mucosal disorder.

Phonation (2 of 4)

Phonation, at E-flat 5 standard illumination, with vibratory blur and still no visible problem.

Subtle swellings (3 of 4)

Only at very high pitch and with high magnification can one see subtle swellings. Here, closed phase of vibration at C# 6 (1106 Hz).

Indicator swellings (4 of 4)

Open phase of vibration, also at C# 6 . Given the patient’s unimpaired “swelling checks,” these findings serve only as an indicator of past and potential over-use of voice, and should not be explained to the patient as being evidence of past problem and potential future problem if over-use again occurs, but, if voice is functioning well, not necessarily as a current problem.

Indicator Lesions and MTD

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Breathy voice (1 of 6)

Distant view at the prephonatory instant in young female singer. There is a wide gap between the cords. The explanation for this gap is not immediately evident, but the voice is breathy.

Phonation (2 of 6)

Phonation has started with margin blurring, and the sense of extra space between the cords remains.

Open phase (3 of 6)

Strobe light, open phase of vibration at B4 (494 Hz)

Closed phase (4 of 6)

Closed phase of vibration, still at B4. Note the incomplete closure posteriorly caused by MTD. Arrows indicate the vocal processes.

Open phase, indicator lesions (5 of 6)

Open phase of vibration, strobe light, at F#5 (740 Hz). Here, the subtle indicator lesions are seen more clearly; vocal cord margins are not perfectly straight.

"Closed" phase, MTD (6 of 6)

“Closed” phase of vibration is not really closed and the vocal processes do not come into full closure, again consistent with MTD.

Use High Voice & Close, Clear View to Reveal What Is Concealed

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Breathing position (1 of 4)

Young woman with singing voice complaints. Speaking voice is normal but swelling checks are strongly impaired. Here, breathing position, standard light, nothing is very noticeable except subtle elevation left vocal cord (right of photo).

Phonation (2 of 4)

Here, high pitch but under standard light and with only moderate magnification, the abnormality is still fairly unimpressive.

Obvious swellings, open phase (3 of 4)

At closer range, using strobe light, and at the same time using fairly high voice (F#5 740 Hz), the obvious margin swellings are seen.

Obvious swellings, closed phase (4 of 4)

Same pitch, closed phase of vibration. Now both vocal and visual findings are indeed obvious. After a trial of speech therapy, vocal cord microsurgery provided return of "original equipment" vocal capabilities.

Vocal Polyp

A large swelling on the vocal cord that typically occurs unilaterally—that is, without a similar swelling on the opposite cord. The term vocal polyp is somewhat imprecise, but vocal polyps can be distinguished from a similar kind of swelling, vocal nodules, in at least two ways: 1) polyps tend to be larger than nodules; 2) polyps occur unilaterally or are markedly larger than an injury of the opposite vocal cord, whereas nodules occur in pairs and are usually similar in size. Both vocal polyps and nodules are caused at least in part by vibratory trauma, due to vocal overuse that is acute (with polyps) or chronic.

A vocal polyp disrupts the voice’s clarity and other capabilities by interfering with accurate approximation of the vocal cords during phonation. A polyp may also add mass to the vocal cord, thereby dropping the pitch range available to the voice. Polyps may be referred to as hemorrhagic, pedunculated, and so forth.


Photos of vocal polyp:

Vocal Polyp, Removed and then Recurring

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Vocal polyp (1 of 4)

The translucency of the left vocal cord polyp (right of image) and the patient's long history of hoarseness together suggest chronicity. Initial voice therapy to manage the patient’s obvious “vocal overdoer” status.

Vocal polyp, one week after surgical removal (3 of 4)

Representative view, one week after microsurgical removal of left vocal cord polyp (right of image). Strobe light, open phase of vibration, with bilaterally equal free margin and phonatory “match.”

Vocal polyp (2 of 4)

Additional view, at diagnosis.

Vocal polyp, subsequent new injury (4 of 4)

Approximately two months later, new injury from persistent vocal overuse.

Vocal Polyp, Before and After Surgery

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Vocal polyp (1 of 6)

An operatic baritone has a chronic left vocal cord polyp (right of image), and small contact reaction, right cord.

Vocal polyp (2 of 6)

Phonation, open phase of vibration, upper middle voice, showing obvious margin elevation of the left cord (right of image). Voice is hoarse.

Vocal polyp (3 of 6)

Maximum closed phase of vibration, showing polyp-induced gap, causing air wasting and hoarse voice quality.

Vocal polyp, surgically removed (4 of 6)

Sixth day after microlaryngoscopic removal of the polyp. Note the red, 2-millimeter “wound” where the polyp was removed.

Vocal polyp, surgically removed (5 of 6)

At extremely high falsetto, open phase of vibration, showing uniform width of glottic chink. Voice is normal, even at this revealing, high pitch.

Vocal polyp, surgically removed (6 of 6)

Closed phase of vibration, high falsetto, shows equal vibratory amplitude on both sides (no stiffness) and excellent match of the cords.

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Vocal polyp (1 of 2)

Chronic polyp on the right vocal cord (left of image), with ectatic capillaries, unresponsive to voice rest and therapy.

Vocal polyp, surgically removed (2 of 2)

Seven weeks after surgical removal and spot coagulation of ectatic capillaries. The margins of the vocal cords now match, and capillaries are normalized. Mucosal vibration is preserved to the highest reaches of the singing range. At this pre-phonatory instant, one can see that muscle memory is keeping the vocal cords slightly apart, suggesting the need for additional speech therapy.

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Vocal polyp (1 of 6)

Prephonatory instant, standard light. The space between the vocal cords is larger than necessary to accommodate the polyp (right of image) and low-profile elevation (left of image).

Vocal polyp (2 of 6)

Phonation with blurring, standard light.

Vocal polyp, surgically removed (3 of 6)

Six days after surgical removal. Prephonatory instant, standard light. Compare with photo 1. The patient continues to position vocal cords in a surprisingly separated position, as though the ghosts of the swellings remain. We call this “gap memory” or “posture memory,” though it is a manifestation as well of muscular tension dysphonia.

Vocal polyp, surgically removed (4 of 6)

Phonation with blurring, standard light. Compare with photo 2.

Vocal polyp, surgically removed (5 of 6)

Phonation, strobe light, open phase of vibration, at high G# (~831 Hz), just below A5. Even at this high pitch, both cords oscillate out to a full lateral excursion.

Vocal polyp, surgically removed (6 of 6)

Phonation, strobe light, closed phase of vibration, also at high G#. Since the patient is only six days postop, mild residual swelling is still present. More importantly, note that this “closed” vibration phase is not in fact fully closed, as further evidence of the patient’s “gap memory” and muscular tension dysphonia. Singing voice-qualified speech therapy and work with a singing teacher will address this.

Translucent Polyp

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Translucent polyp (1 of 4)

Close-range view with vocal cords in abducted position. This is not the best view to see translucence but faintly “grey” tone of polyps (circled by dotted lines) is indicator of translucence.

Translucent polyp (2 of 4)

As vocal cords are coming towards adduction, grey indicator of translucence.

Translucent polyp (3 of 4)

Similar view, with elicitation of rapid inspiration to reveal polyps better, especially on left (right of image).

Translucent polyp (4 of 4)

During strobe illumination, translucence especially of the right vocal cord (left of image), is seen best. Note that the larger polyp rides on the margin of the left vocal cord (right of image).

Opera Singer’s Polyp Removed with Restoration of Original Capabilities

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Polyp and capillary ectasia (1 of 8)

Right vocal cord polyp (left of photo) and bilateral capillary ectasia. This young man continues to perform successfully but with increased effort, reduced endurance, impaired falsetto.

Prephonatory instant (2 of 8)

Prephonatory instant (standard light, just before vibratory blur) at high pitch to make the polyp maximally evident.

One week post-op (3 of 8)

One week after microsurgical removal and spot-coagulation of ectasia.

Prephonatory instant (4 of 8)

Prephonatory instant at B4 (494 Hz) (compare with photo 2).

One month post-op (5 of 8)

One month after surgery, original vocal capabilities are restored. A tiny ectatic capillary “escaped.” It can be observed or spot-coagulated in an office setting using the pulsed-KTP laser.

Prephonatory instant (6 of 8)

Prephonatory instant shows straight margins and excellent “margin match.”

Closed phase (7 of 8)

Strobe light, closed phase of vibration. This is performed at E-flat 5 (high falsetto), in order to maximally “reveal” (if present) vibratory stiffness.

Open phase (8 of 8)

Open phase shows equal lateral excursion of both cords: there is no stiffness, and the residual irregularity is on the left (un-operated) cord (right of photo).

An Actress’ Polyp Before and Hours After Surgical Removal

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Vocal cord polyp (1 of 8)

Musical theater actress with chronic hoarseness due to this right vocal cord polyp (left of photo), first identified a year earlier and unresponsive to speech therapy.

Closer view (2 of 8)

Magnified view shows small elevation of the left cord (right of photo) as well.

Closed phase (3 of 8)

Closed phase of vibration (strobe light) at B flat 5 (932 Hz).

Open phase (4 of 8)

Open phase at same pitch.

24 hours post surgery (5 of 8)

The next day, only a few hours after surgical removal. Note slight bruising from the endotracheal tube (long arrows), and small dots where a laser impact was used to interrupt flow in a prominent capillary (short arrows).

Primary “wound” (6 of 8)

Magnified view. Primary “wound” from polyp removal is at the arrows. Edema of the opposite side is from minimal trimming on that side.

Closed phase (7 of 8)

Closed phase of vibration, strobe light, at D5 (587 Hz). Increased mucus is from endotracheal tube and surgical manipulation just hours earlier.

Open phase (8 of 8)

Open phase, at same pitch. Subtle irregularities will “iron out” within over time. Voice is already much better (tested briefly because the patient is within the four days of voice rest, and then will gradually increase amounts of voice use for the subsequent month).

Operated Cord Looks Better than the Unoperated Cord

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Singer with chronic hoarseness (1 of 4)

Chronic hoarseness in a singer. The obvious abnormality is on the left vocal cord (right of photo).

Attempting phonation (2 of 4)

When trying to make sound at high pitch, the polyp comes into early contact and interferes with vibration. Chaotic vibration will not allow full evaluation of the right (more normal) looking side.

One week post surgical removal (3 of 4)

A week after surgical removal, voice is dramatically restored to the patient's complete satisfaction, and the vocal cord margins can match accurately, as seen under strobe light.

Open phase (4 of 4)

Open phase of vibration at very high pitch, which the patient can now produce, reveals subtle margin elevation on the right (unoperated) side (left of photo). This is an example of how "the operated cord often looks better than the unoperated one."

Office Laser of Post-radiation Telangiectatic Polyp

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Post-radiation telangiectasias (1 of 4)

Years after radiotherapy for vocal cord cancer, the exaggerated capillaries are not typical capillary ectasia, but instead post-radiation telangiectasias. The "polyp" may be also radiation-related because there is no history of voice over-use.

Pulsed-KTP coagulation (2 of 4)

At the conclusion of pulsed-KTP coagulation of the "polyp."

"Polyp" pulled off (3 of 4)

The "polyp" has pulled off with the fiber.

Three weeks later (4 of 4)

Three weeks later, the vocal cords now match, voice is improved, and the site of surgery (arrow) is healed.

Nuances “Gleaned” from Daily Examinations

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Vocal "overdoer" (1 of 4)

A vocal “overdoer” with hoarseness. Note broad-based swelling of both vocal cord margins. A microweb, thought to be congenital, is also seen at the arrow. Tiny dots indicate a subtle wrinkle or shallow sulcus.

Inspiratory phonation (2 of 4)

The patient has been asked to produce inspiratory phonation to reveal the translucent polyp and “sulcus,” again at tiny dots.

Translucent polyp (3 of 4)

Under strobe light, the translucence of the polypoid elevation is seen more clearly.

Open phase (4 of 4)

At open phase of vibration again under strobe light, the broad based left vocal cord elevation is also seen.

The Mucosa’s Expression of Injury Varies

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Vocal cord injuries (1 of 4)

Vocal cord injuries of overuse are often bilaterally similar, but here we have two quite different expressions of injury: fibrosis and capillary ectasia on left (right of photo); translucent polypoid injury (not a cyst) on the right (left of photo).

Narrow band lighting (2 of 4)

Now under narrow band light, the left cord (right of picture) has a flatter, fibrotic expression with tiny ectatic capillaries.

Strobe lighting (3 of 4)

Under strobe light, the translucent, polypoid nodule of the right cord (left of photo) distorts vibratory closure.

Phonation (4 of 4)

This is the best closure this grossly hoarse person can achieve.

The Power of “Close-clear” Not “Far-fuzzy” to See a Polyp

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Disant view (1 of 4)

This man is a singer. Distant "far" examination shows what appears to be a subtle or even inconsequential elevation of his right vocal cord (left of photo).

Closer view (2 of 4)

Closer view shows the lesion better, but its true magnitude is about to be seen...when a truly close-clear view is achieved.

Close-clear view (3 of 4)

Close-clear view under strobe light , falsetto voice, closed phase of vibration. The broad-based swelling is more clearly seen, between the two dots.

Open phase (4 of 4)

Open phase of vibration again shows the injury.

Polyp or Cyst?

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Hoarseness (1 of 4)

During an upper respiratory infection, this older woman developed hoarseness that has not gone away during the past year. Is this the end stage perhaps of a hemorrhagic polyp?

Position of lesion (2 of 4)

In this slightly closer view, with the patient breathing out, the lesion appears too “high” within the laryngeal vestibule, and not truly at the level of the vocal cords.

Close view (3 of 4)

This close view is on the way to determining if there is any attachment to the vocal cords themselves. Not quite yet able to tell…

Anterior saccular cyst (4 of 4)

The tip of the scope has just passed the lesion and the vocal cords are unaffected. As it appears to be arising from the ventricle, it could be classified as an anterior saccular cyst. Likely the saccule or a mucus gland became plugged due to inflammation during the upper respiratory infection a year earlier, and it filled with mucus.

Tiny Vibrating Segment Gives Tiny Tin Whistle Voice

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Prephonatory instant (1 of 6)

This young woman has been hoarse for many years. This preparatory posture shows marked separation of the cords posteriorly, suggesting MTD as well.

Phonation (2 of 6)

Now producing voice, with vibratory blur of the entire length of the cords on both sides.

Gaps due to nodules (3 of 6)

Under strobe light at a lower pitch of A4 (440 Hz), closed phase of vibration. Large gaps anterior and posterior to the polypoid nodule(s) explain breathy quality and short phonation time.

Open phase (4 of 6)

Open phase of vibration also at A4 (440 Hz) shows that the full length of the vocal cords are vibrating. Compare with the following two photos.

"Tin whistle" sound (5 of 6)

Now at A5 (880 Hz), the patient can only make an extremely tiny (tin whistle) quality. The only segment vibrating is within the circle (here, closed phase). The posterior segment does not vibrate.

"Tin whistle" at open vibration (6 of 6)

Still at A5 (880 Hz), the open phase of vibration, again of *only* the tiny anterior segment.

Smoker’s Polyp Reduction Improves Voice Even Though the Larynx Result May not be “Pretty”

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Smokers Polyp (1 of 5)

Six years after vocal polyp removal elsewhere. As a result of continued smoking, the voice is deep and rough, and an obvious recurrent/residual "smoker's" polyp is seen on the right vocal cord(arrow, left of photo). The patient "hates" her rough and masculine voice quality.

Reine's edema (2 of 5)

Inspiratory phonation is elicited to "pull" the redundant tissue medially, revealing a lot of Reine's edema of the left vocal cord, too. The dotted lines show the ellipse of mucosa that will be removed during surgery. Mucose will be preserved at the margins and the gelatinous lateral within the polyps will be suctioned away if liquid, and dissected away if fibrotic.

A week after surgery (3 of 5)

The dotted lines show the extent of mucosal excision—an area that will take a few weeks to re-mucosalize. Since this was a polyp "reduction," though hoarse this early post, she has a " functional" voice. There should be no alarm if patients are aphonic for a week or even a few weeks while inflammation resolves.

Residual Reinke's edema (4 of 5)

At two months post, the patient is very pleased and says the improvement to voice is "large." Here, it appears there may be some residual Reinke's edema especially of the left vocal cord (right of photo) judging by the slightly convex margin.

Residual submucosal edema (5 of 5)

With inspiratory phonation, the residual submucosal edema is made obvious, especially on the left. This was (as intended) a polyp "reduction" approach, rather than polyp "removal" as the latter is too hard on voice, and it is not possible to "put back" if too much tissue is taken. Here, there is no stiffness, and if desired, more can be removed. Of course, since the patient is so pleased with her voice, no further treatment is needed.

Audio :

Patient comments about the improvement of voice after surgical removal of a vocal cord polyp.

Audio with photos:

Voice quality, with a vocal polyp, BEFORE surgery (see this patient’s photos just below):

Same patient, AFTER surgery:


Videos:

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.

Vocal Nodules

Small chronic swellings that appear in the junction of the middle and anterior thirds of the vocal fold. These swellings, or nodules (nodes), are vibratory injuries caused by vocal overuse. The most obvious symptom of medium-to-large nodules tends to be hoarseness. The top symptoms for nodules of any size may include: 1) difficulty with high, soft singing; 2) day-to-day variability of vocal capability and clarity; 3) a sense of increased effort to produce voice, especially for singing; 4) reduced endurance, so that the voice becomes husky or “tired” after less voice use than formerly; and 5) phonatory onset delays, when there is a slight hiss of air before the voice “pops in.”

How nodules happen:

When you overuse your voice, your body tries to cushion the vocal cords by pooling together edema (fluid) beneath the vocal cord mucosa (the surface layer of the cords); this pooled edema is like a small, low-profile blister on your finger. If after a few days you stop overusing your voice, the edema disperses readily, within a few days, and this “blister” on the vocal cords vanishes. If, however, the amount or manner of voice use remains excessive for many weeks or months, then more chronic swelling materials (no longer just edema fluid) are laid down by the body, and the vocal cords develop true nodules.

Why nodes affect the voice:

In either case (acute swellings or chronic nodules), this injury to the mucosa can impair the voice in two ways: it reduces the vibratory flexibility of the mucosa, and it interferes with the accurate match of the cords when they come together to produce voice. This impairment causes the voice to be hoarse or, more subtly, to suffer from onset delays, difficulty with high notes, and other similar problems.

Treatment:

Nodules will often dissipate, with the help of rest and perhaps speech/voice therapy, over a period of weeks or months. Sometimes, the swellings are so stubborn that surgery is required.


Audio with photos:

Vocal nodules’ effect on the voice, BEFORE surgical removal (see this patient’s photos just below):

Same patient, seven weeks AFTER surgical removal of the vocal nodules:

Vocal Nodules, Before and After Surgery

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Vocal nodules (1 of 6)

Strobe light, phonation, open phase of vibration, at the pitch D5 (~587 Hz). There are vocal nodules on both vocal cords, of very long duration, even after voice rest and speech therapy. Compare with photos 3 and 5.

Breathy voice (2 of 6)

Same as photo 1, but during the closed phase of vibration. The nodules keep the vocal cords from coming together completely (as seen here), making the patient’s voice breathy. Compare with photos 4 and 6.

1 week after surgery (3 of 6)

One week after surgical removal of the vocal nodules. Strobe light, phonation, open phase of vibration, at the pitch B5 (~988 Hz). (The small “blob” seen at the midpoint of the cords is just incidental mucus.)

Closed phase (4 of 6)

Same as photo 3, but during the closed phase of vibration.

7 weeks after surgery (5 of 6)

Seven weeks after surgical removal of the nodules. Strobe light, phonation, open phase of vibration, at the pitch C#6 (~1109 Hz). (Incidental mucus is obscuring the posterior end of the vocal cords.)

7 weeks after surgery (6 of 6)

Same as photo 5, but during the closed phase of vibration. Voice is no longer breathy, and the upper range has been restored.

Photos:

Polypoid Vocal Nodules

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Polypoid vocal nodules (1 of 4)

Polypoid vocal nodules in a “vocal overdoer” with phenomenology typical for a mucosal injury. Narrow band illumination (blue-green light) makes vasculature more prominent. Note also the fusiform (long, low-profile) swelling, best seen on the left cord (right of image).

Incomplete closure (2 of 4)

Phonation, strobe light, at the beginning of the closed phase of vibration; one can see that closure will be incomplete due to early contact of the polypoid nodules.

Polypoid vocal nodules (3 of 4)

Phonation, strobe light, closed phase of vibration, with persistent gaps anterior and posterior to the polypoid nodules.

Polypoid vocal nodules (4 of 4)

Phonation, strobe light, open phase of vibration, continues to show the mid-cord swellings.

Vocal Nodules, Leukoplakia, and Capillary Ectasia

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Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)

Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.

Vocal nodules, leukoplakia, and capillary ectasia (2 of 4)

Prephonatory instant, standard light.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)

Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)

Strobe light, moving towards closed phase of vibration.

Vocal Nodules, Before and After Surgery

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Vocal nodules (1 of 10)

Vocal nodules under standard light. Note asymmetry in size.

Prephonatory instant (2 of 10)

Prephonatory instant, standard light.

Translucency (3 of 10)

Closed phase of vibration, with notable translucency of the right vocal cord (left of image), which is often a predictor of chronicity and only partial response to speech (voice) therapy.

Open phase (4 of 10)

Open phase of vibration, strobe light.

1 week after surgery (5 of 10)

A week after vocal cord microsurgery, standard light.

1 week after surgery (6 of 10)

Open phase of vibration, strobe light.

1 week after surgery (7 of 10)

Closed phase of vibration, strobe light, showing tiny margin elevations, bilaterally.

Vocal nodules: 10 weeks after surgery (8 of 10)

Prephonatory instant shows recurrent swelling due to persistent vocal overuse, despite careful preoperative preparation for surgery by a voice-qualified speech pathologist. Patients must know “we are only operating on your vocal cords, not your personality, occupation, friend group, social life, etc.”

10 weeks after surgery (9 of 10)

Open phase of vibration, strobe light.

10 weeks after surgery (10 of 10)

Closed phase of vibration, strobe light. The “original equipment” capabilities of the voice early after successful vocal cord microsurgery (above) have been diminished, but capabilities remain markedly better than they were with the original lesions.

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Vocal nodules (1 of 4)

Vocal nodules, moderately large, seen with cords in abducted (breathing) position.

Phonation (2 of 4)

Phonation, showing early contact of the nodules, and large gaps anterior and posterior to the nodules.

After surgery (3 of 4)

Phonatory position, after surgical removal. Note the straightened vocal cord margins.

After surgery (4 of 4)

Breathing position, also post-surgery.

Vocal Nodules

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Vocal nodules (1 of 4)

Vocal nodules, with cords in abducted (breathing) position. Note also a thin layer of mucus.

Prephonatory instant (2 of 4)

Vocal nodules at prephonatory instant under standard illumination.

Open phase of vibration (3 of 4)

Under strobe light, open phase of vibration.

Closed phase of vibration (4 of 4)

Under strobe light, closed phase of vibration.

Vocal Nodules, Spicule-shaped

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Vocal nodules (1 of 3)

Open phase of vibration just as vocal cords are also parting (to assume breathing position), strobe light. Note the small “spicule” nodules; these are at the other end of the continuum from “fusiform” or “broad-based” nodules.

During phonation (2 of 3)

Strobe light, high-pitched voice, showing early contact of the spicule-form nodules.

Closed phase (3 of 3)

Closed phase of vibration at lower pitch, strobe light.

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Vocal nodules (1 of 4)

Small, spicule-shaped nodules, in a soprano singer, as seen under standard light, in breathing position. This class of nodules is sometimes thought to have no potential to affect the voice (unlike broader-based, fusiform nodules).

Small nodules (2 of 4)

As the vocal cords approach each other to produce voice, note the pointed shape of these small nodules.

Phonation (3 of 4)

Phonation, under strobe light, closed phase of vibration, at the pitch C4 (~262 Hz). This patient's voice is notably impaired.

Open phase (4 of 4)

Open phase of vibration, showing again the spicule-shaped nodules.

Vocal Nodules, Before and After Surgery

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Vocal nodules, before surgery (1 of 4)

Young sociable woman in sales, with chronic hoarseness due to broad-based “polypoid nodules.” Breathing position, standard light.

Before surgery (2 of 4)

Making voice at C5 (~523 Hz), showing large swelling on the right cord (left of photo), and lower-profile one on the opposite cord.

After surgery (3 of 4)

Seven days after vocal cord microsurgery; breathing position, standard light. Although there is mild residual post-surgical inflammation of the left cord margin (right of photo), the voice is already markedly improved and normal-sounding. Compare with photo 1.

Vocal nodules, after surgery (4 of 4)

Making voice at A5 (880 Hz). The vocal cords match accurately and both oscillate, despite mild broad-based inflammatory swelling of the left cord margin (right of photo). Compare with photo 2.

Fibrotic Nodules

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Fibrotic nodules (1 of 5)

This patient, a physical education instructor, has through vocal overuse developed the broad-based, rounded swellings seen here on each vocal cord. These swellings lack the watery or translucent appearance associated with edema swelling, because they are stiffer and more fibrotic.

Fibrotic nodules: full-length vibration at low pitch (2 of 5)

Phonation at low pitch, under strobe light, at moment of vocal cord contact (closed phase of vibration). At this pitch, the vocal cords are vibrating along their full length. (Ignore the small amount of whitish mucus.)

Fibrotic nodules: full-length vibration at low pitch (3 of 5)

Phonation at low pitch again, but now at the open phase of vibration.

Fibrotic nodules: segmental vibration at high pitch (4 of 5)

Phonation, very high pitch, closed phase of vibration. Now only the segment of the vocal cords indicated by the dotted lines is vibrating.

Fibrotic nodules: segmental vibration at high pitch (5 of 5)

Phonation, very high pitch, open phase of vibration. Again, there is only segmental vibration, indicated by the dotted lines.

Vocal Nodules

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Vocal nodules (1 of 2)

Note that the nodules are not seen well during breathing (abducted position).

Vocal nodules (2 of 2)

In the same patient, these fusiform vocal nodules are easily seen at the prephonatory instant, and of course (not shown here) under strobe illumination.

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Vocal nodules (1 of 1)

Note the asymmetry, with the nodule on the right cord (left of image) larger than left, and incomplete phonatory closure, causing breathy voice quality and loss of expected upper range.

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Vocal nodules (1 of 1)

Greatly increased glottal mucus, likely related to acid reflux, and subtle, hazy leukoplakia.

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Vocal nodule (1 of 1)

This nodule's translucence (indicated by the arrow) is often an indicator of chronicity and that the lesion may eventually require surgery.

Vocal Cord ‘Wounds,’ 2 Hours after Surgery

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Polypoid nodule, open phase (1 of 8)

Man in mid-30’s with chronic hoarseness due to boisterous personality, and work voice demands. Open phase vibration, low pitch shows large left cord (right of photo) polypoid nodule.

Polypoid nodule, closed phase (2 of 8)

Closed phase, at same low pitch, mostly conceals the injury.

Polypoid nodule, right and left cords (3 of 8)

Still at same low pitch, the early ‘closing’ phase shows the right sided (left of photo) polypoid nodule, and the larger left-sided lesion (right of photo).

Segmental vibration (4 of 8)

At high pitch, vibration is damped in mid and posterior cords, and only the anterior segment vibrates at arrows.

Post-surgery wounds (5 of 8)

Two hours after microsurgical removal of the lesions, the fresh, 3-mm “wounds” are seen at close range.

Post-surgery, closed phase (6 of 8)

View while making voice shows straight-line match of the vocal cord margins, and equal bilateral blurring, preliminarily suggesting preserved vibratory ability. Compare with photos 1-4.

Post-surgery, open phase (7 of 8)

Open phase of vibration at E-flat 4 (311 Hz). The patient was unable to make this pitch just 2 hours earlier. Compare with photo 3.

Post-surgery, precise match (8 of 8)

Closed phase vibration, also at E-flat 4, showing precise match, and verifying bilaterally equal mucosal oscillatory ability. Increased mucus is from the irritation of recent surgery.

Fibrosis as a Base to Nodules, Before and After Surgery

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Bilateral polypoid nodules (1 of 8)

Fibrosis as a Base to Nodules, Before and After Surgery

Narrow-band lighting (2 of 8)

At greater magnification, and also under narrow-band light. The area of fibrosis is more clearly seen, now without the dotted lines.

Closed phase (3 of 8)

Closed phase of vibration at ~A4 (440 Hz), as seen under strobe light.

Open phase (4 of 8)

Open phase of vibration also at ~ A4.

Two weeks after surgery (5 of 8)

Less than two weeks after surgical removal of the polyps. The faint white zone of margin fibrosis is again seen. Compare with photo 1.

Phonation (6 of 8)

Phonation under standard light shows that vocal cord margins now match, and both margins blur; suggesting vibratory flexibility.

Margin fibrosis (7 of 8)

Closed phase of vibration, at ~ A4 (440 Hz), as seen under strobe light. Margin fibrosis seen best here, indicated by the black dotted line. Compare with photo 3.

Open phase (8 of 8)

Open phase of vibration. The same pitch (A4) reveals excellent vibratory flexibility and equal amplitude (lateral excursion) of vibration. Compare with photo 4.

Pre-and 1 Week Post-removal Vocal Nodules

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Vocal nodules (1 of 8)

Semi-professional high soprano with grossly impaired upper voice due to polypoid (fusiform) vocal nodule.

Muscular tension dysphonia (2 of 8)

Phonatory view shows a degree of muscular tension dysphonia (separated vocal processes), too.

Open phase (3 of 8)

Nearly open phase under strobe light at B4 (494 Hz).

Closed phase (4 of 8)

Closed phase of vibration, aslo at B4.

Post-op, one week (5 of 8)

A week after surgical removal of the nodules, at the prephonatory instant, D5, showing margin irregularity.

Phonation (6 of 8)

Phonation, with vibratory blur under standard light.

Open phase (7 of 8)

Open phase of vibration (strobe light), at D5 (587 Hz). Irregular margins will iron out across time.

Closed phase (8 of 8)

At closed phase of vibration, also at D5. Note excellent match, bilaterally equal vibratory excursions, and partial correction of the MTD posterior commissure gap.

Vocal Nodule Postop Irregularity yet Match and Flexibility

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Large vocal nodules (1 of 8)

Bilateral large vocal nodules in band singer that does close harmony musical styles.

Narrow band light (2 of 8)

Now under narrow band light to accentuate the vascular pattern.

At B2 (3 of 8)

At low pitch (B2 or 123 Hz).

At A5 (4 of 8)

At A5 (880 Hz).

One week after surgery (5 of 8)

A week after surgery, the “wounds” measure about 3mm long (at arrows).

Prephonatory instant (6 of 8)

Prephonatory instant, standard light, at C#5 (554 Hz).

Closed phase (8 of 8)

Closed phase, also at E5.

Open phase (7 of 8)

Open phase of vibration at E5 (659 Hz). Voice is markedly improved.

Search not Only for Nodules, but Also for Segmental Vibration and Look at the Posterior Commissure for MTD

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Open phase (1 of 4)

In a young pop-style singer, the open phase of vibration under strobe light at C#5 (554 Hz). This magnified view is best to see the large fusiform nodules.

Closed phase (2 of 4)

Closed phase of vibration at the same pitch shows touch closure—that is, that the nodules barely come into contact.

Segmental vibration (3 of 4)

Even when patients are grossly impaired in the upper voice as is the case here, the clinician always requests an attempt to produce voice above G5 (784 Hz), in order to detect segmental vibration. Here, the pitch suddenly breaks to a tiny, crystal-clear D6 (1175 Hz) Only the anterior segment (arrows) vibrates.

Posterior commissure (4 of 4)

A more panoramic view that intentionally includes the posterior commissure to show that the vocal processes, covered by the more ‘grey’ mucosa (arrows), do not come into contact. This failure to close posteriorly is a primary visual finding of muscular tension dysphonia posturing abnormality.

“Kissing” Tonsils

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