Inability to Burp or Belch

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple,” directly behind the cricoid cartilage.

If you care to see this on a model, look at the photos below. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching. The formal name for this disorder is retrograde cricopharyngeus dysfunction (R-CPD).

People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success.

The person so wants and needs to burp, but continues to experience this inability to burp. Sometimes this can even be painful. Such people often experience chest pressure or abdominal bloating, and even abdominal distention. Flatulence is also severe in most persons with R-CPD. Other less universal symptoms are nausea after eating, painful hiccups, hypersalivation, or a feeling of difficulty breathing with exertion when “full of air.” Many persons with R-CPD have undergone extensive testing and treatment trials without benefit. R-CPD reduces quality of life, and is often socially disruptive and anxiety-provoking. Common (incorrect) diagnoses are “acid reflux” and “irritable bowel syndrome,” and therefore treatments for these conditions do not relieve symptoms significantly.

Approaches for treating the inability to burp:

For people who match the syndrome of:
1) Inability to belch
2) Gurgling noises
3) Chest/abdominal pressure and bloating
4) Flatulence

Here is the most efficient way forward: First, a consultation to determine whether or not the criteria for diagnosing R-CPD are met. Next, a simple office-based videoendoscopic swallow study which incorporates a neurological examination of tongue, pharynx (throat) and larynx muscles and often includes a mini-esophagoscopy. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this straightforward office consultation and swallowing evaluation establishes the diagnosis of retrograde cricopharyngeus dysfunction (non-relaxation).

The second step is to place Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized.

The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem. Furthermore, based upon an experience with more than 890 patients as of August 2019, a single injection appears to “train” the patient how to burp. Approximately 80% of patients have maintained the ability to burp long after the effect of the Botox has dissipated. That is, long past 6 months from the time of injection.

Patients treated for R-CPD as just described should experience dramatic relief of their symptoms. And to repeat, our experience in treating more than 890 patients (and counting) suggests that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to burp. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or might even elect to undergo endoscopic laser cricopharyngeus myotomy. To learn more about this condition, see Dr. Bastian’s description of his experience with the first 51 of his much larger caseload.

Check out our list of resources containing peer-reviewed articles, patient stories and more!


Photos of the cricopharyngeus muscle:

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Cricopharyngeus Muscle (1 of 3)

The highlighted oval represents the location of the cricopharyngeus muscle.

Cricopharyngeus Muscle (2 of 3)

The cricopharyngeus muscles in the open position.

Contracted Cricopharyngeus Muscle (3 of 3)

The cricopharyngeus muscle in the contracted position.

Esophageal Findings

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Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

Abdominal Distention of R-CPD

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

A Rare “abdominal crisis” Due to R-CPD (inability to burp)

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X-Ray of Abdominal Bloating (1 of 2)

This young man had an abdominal crisis related to R-CPD. He has had lifelong symptoms of classic R-CPD: inability to burp, gurgling, bloating, and flatulence. During a time of particular discomfort, he unfortunately took a “remedy” that was carbonated. Here you see a massive stomach air bubble. A lot of his intestines are air-filled and pressed up and to his right (left of photo, at arrow). The internal pressure within his abdomen also shut off his ability to pass gas. Note arrow pointing to lack of gas in the descending colon/rectum. NG decompression of his stomach allowed him to resume passing gas, returning him to his baseline “daily misery” of R-CPD.

X-Ray of Abdominal Bloating (2 of 2)

X-Ray without markings

Can’t Burp: Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated. 

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Mild distension (2 of 6)

Also early in the day, a front view, showing again mild distention.

Front view (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Another view (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

Shortness of Breath Caused by No-Burp (R-CPD)

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath. 

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

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Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

Dramatic Lateral Dilation of the Upper Esophagus

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(1 of 3)

This photo is at the level of (estimated) C6 of the spine (at S). This person has known cervical arthritis, accounting for the prominence. Opposite the spine is the trachea (T). Note the remarkable lateral dilation (arrows) in this picture obtained with with no insufflated air using a 3.6mm ENF-VQ scope. It is the patient’s own air keeping the esophagus open for viewing.

(2 of 3)

At a moment when air from below further dilates the upper esophagus, the tracheal outline is particularly well-seen (T) opposite the spine (S). The “width” of the trachea indicated further emphasizes the degree of lateral dilation, which is necessary because spine and trachea resist anteroposterior dilation.

(3 of 3)

Just for interest, at mid-esophagus, the familiar aortic “shelf” is seen. Again, this esophagus is being viewed with a 3.6 mm scope with only the patient own (un-burped) air allowing this view.

What the Esophagus Can Look Like “Below A Burp”

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Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.

Where have no-burpers traveled from?


R-CPD patients BVI treated across the USA

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.


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.


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.

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.


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.


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.


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.



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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).


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.

Cryptococcus Neoformans

Cryptococcus neoformans laryngitis is a rare fungal infection of the larynx. The infection usually occurs as a primary pulmonary infection but can spread to other regions of the body. Common characteristics of cryptococcus neoformans include longstanding hoarseness, sore throat, or edema of the vocal cords. Cryptococcus neoformans laryngitis is treated with oral anti-fungal medications such as fluconazole.

Photos of cryptococcus neoformans:

Cryptococcus Infection of the Larynx

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Panoramic view (1 of 4)

Panoramic view of laryngeal vestibule in a man with very longstanding hoarseness and sore throat. Note intense redness and bumpy mucosal surface. Biopsy revealed Cryptococcus neoformans.

Closer view (2 of 4)

Closer view of the vocal cords shows similar intense inflammation and rough surface.

One year later (3 of 4)

After a one-year course of fluconazole, an oral anti-fungal medication. Symptoms are gone. The larynx is no longer inflamed, and the mucosal surface is smooth. White area of scarring (dotted surround), and scar band (parallel dotted lines).

One year later, close-up (4 of 4)

Close-up of the vocal cords shows similar resolution of redness and cobblestoned surface.

4 years later (5 of 6)

The patient has been lost to followup and re-presented with increased hoarseness and sore throat. Here, we see what appears to be recrudescence of the infection with granularity throughout the laryngeal vestibule.

Fungal re-growth (6 of 6)

At closer range, note the granularity of laryngeal petiole and false vocal cords. The vocal cords are in the distance, but also involved by the fungal re-growth.


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


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Six years post SLAD-R (1 of 4)

Six years after SLAD-R performed elsewhere. Note that re-innervation appears greater for left (right of photo) than right (left of photo) thyroarytenoid (TA) muscle. Signs of continuing atrophy of the TA muscle within the right cord (left of photo) include capacious ventricle ('V'); absence of “conus” ('C') bulk below the free margin (see contrast between /--/ on both sides); slight concavity or bowing of the free margin; and narrower band of the vocal cord itself that we sometimes refer to as the “spaghetti-linguini” larynx.

TA + LCA muscles (2 of 4)

While TA is more recovered on the left (right of photo) as seen in photo 1, here we see that the lateral cricoarytenoid (LCA) muscle has recovered more on the right (left of photo). At the prephonatory instant, the failure of the left (right of photo) vocal process to turn to the midline indicates continuing weakness of the LCA muscle.

Greater amplitude of right cord (3 of 4)

Under strobe illumination, open phase of vibration shows greater amplitude of right cord (left of photo), consistent with the atrophy of the permanently somewhat weak TA muscle seen in photo 1.

Patient has returned to Botox (4 of 4)

Closed phase of vibration. A few years after SLAD-R, this man’s spasms recurred sufficiently that he has resumed Botox injections.


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

Pharyngeal Paralysis

The pharynx (loosely “throat”) has a “foodway” function to convey food and liquid from the mouth to the esophagus. It also serves as part of the “airway,” also from mouth into the larynx and trachea. These foodway/airway functions are kept separate so food and liquid do not enter the airway towards the lungs. At the moment of swallowing, vocal cords clamp firmly together and epiglottis drops over the entrance of the larynx to divert food and liquid into the esophagus. During each swallow, lasting perhaps a second, breathing is briefly suspended. Once the food/liquid has gone by, the larynx re-opens and breathing resumes.

A thin sheet of muscle surrounds the pharynx, and squeezes to narrow the pharynx and help to propel swallowed material. That contraction lasts for approximately one second, each time the person swallows. The muscle is innervated bilaterally by the pharyngeal branch of the vagus nerve and so one side or both sides can be paralyzed by tumor, fracture at the base of the skull, viral injury, etc.

This diagnosis is often overlooked, because clinicians may not be clear on how to make the diagnosis. The best way is to obtain a clear panoramic view of the laryngopharynx as seen in the photo series below, and ask the patient to produce a very high pitch. This maneuver “recruits” contraction of the pharynx outside of the act of swallowing and allows the examiner to see clearly the difference in the contraction of the two sides. The paralyzed side is pulled to the non-paralyzed side, again as seen below.

Some with unilateral pharynx paralysis can compensate and continue to swallow (with limitations). Others are completely unable to surmount the impediment of this kind of paralysis.

High Vagus Nerve Injury

The vagus (10th cranial) nerve originates from the medulla (part of the brainstem), exits from the base of the skull through the jugular foramen, and among other things, supplies branches to the musculature of palate, pharynx, and larynx. Location of vagus nerve injury is sometimes evident by palate and pharynx findings. But these findings are sometimes overlooked as in this case, especially if palate and pharynx are weak but not completely paralyzed.

Case study: This 50-something woman developed a weak voice and moderate difficulty swallowing upon awakening 5 months prior to this visit. Fortunately, her symptoms of weak voice and difficulty swallowing were not devastating, and are improving. But up to this examination, there has been no diagnosis. This examination reveals a “lesion” of her right vagus nerve and it has to be at the base of the skull because palate, pharynx, and larynx muscles are all weak. Voice is functional but lacks the ability to project and has a “soft-edged” quality. A sophisticated listener can also hear mild hypernasality. The examination below prompts a scan with special attention to base of skull to be sure there is no mass lesion there.

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Nasopharynx (1 of 7)

This view of the nasopharynx shows that soft palate elevates and deviates to the left (curved arrow). The right side of the palate is atrophic and there is a gap (straight arrow) when she speaks. Saliva on the back wall of the nasopharynx (where it doesn’t belong) is also a clue.

Saliva pooling in right pyriform sinus (2 of 7)

Initial view of the hypopharynx shows saliva pooling preferentially in the right pyriform sinus at *. This is a typical finding of right pharynx paresis or paralysis.

Pharynx contracts (3 of 7)

To “prove” that the pharynx is weak on the right, the patient is asked to produce a very high pitch to recruit pharynx contraction. The midline (dashed line) has deviated far to the left (right of photo). Pharynx contracts on the left (arrows), closing the pyriform sinus on that side. There is no corresponding contraction on the patient’s right (left of photo).

Swallowing blue applesauce (4 of 7)

Blue-stained applesauce the patient has attempted to swallow replaces the saliva in the right pyriform sinus, but there is no soiling of the laryngeal vestibule (initial opening to the airway).

Unilateral pharynx contraction (5 of 7)

Elicitation of the “pharyngeal squeeze” with high pitched voice re-demonstrates unilateral pharynx contraction (arrows).

Right vocal cord paresis (6 of 7)

Closer inspection of larynx shows right vocal cord paresis (LCA and TA seem mostly intact explaining reasonably functional voice).

Vocal cord is paretic, not paralyzed (7 of 7)

Phonation shows fairly good vocal cord approximation, again showing that the cord is paretic rather than paralyzed, and explaining the fairly functional voice. Despite having swallowed several boluses of blue applesauce and water, the laryngeal vestibule shows no soiling, explaining why the patient is managing her swallowing even though she is aware that it is abnormal.

Pharyngeal Paralysis, Seen with Pharynx Contraction

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Pharyngeal paralysis (1 of 2)

View of the laryngopharynx. This patient has pharyngeal paralysis on one side, which is already slightly evident because the posterior pharyngeal wall's midline (dotted line) is deviating here slightly to one side, even at rest.

Pharyngeal paralysis, more obvious with pharynx contraction (2 of 2)

The pharynx is contracted, and the posterior pharyngeal wall (midline again at dotted line) now deviates dramatically toward the non-paralyzed side of the pharynx. This pharynx contraction was elicited via extremely high-pitched voicing.

Pharyngeal Paralysis

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Pharyngeal paralysis (1 of 1)

Panorama of the laryngopharynx. Note the capacious left pyriform sinus (right of photo), one strong indicator of paralysis of the pharynx on that side.
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Pharyngeal paralysis (1 of 1)

Blue-stained water swallowed by the patient has preferentially pooled in the left pyriform sinus (right of image), due to weakness of the left inferior pharyngeal constrictors.


Also known as laryngotracheitis or laryngotracheobronchitis, croup 1 is a primarily pediatric viral disease affecting the larynx and trachea. Though it may resemble a simple cold at first, the infection causes a loud barking cough and stridor (unusual, high-pitched breathing noises indicating partial airway obstruction). The majority of cases are caused by parainfluenza viruses (types 1, 2, and 3) but a variety of other viruses can lead to croup symptoms.

The central problem for patients with croup is the swelling of the subglottic region of the larynx, which is the narrowest part of the airway in children. It can vary in its severity and can last anywhere from three days to two weeks. Most patients do not require hospitalization, as home treatment or prescribed antibiotics or steroids are typically sufficient.

Croup, aka Laryngotracheitis:

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Croup, aka laryngotracheitis (1 of 4)

Though croup is most often seen in children, this woman developed a barking cough and mild, non-anxiety provoking stridor in the context of an upper respiratory infection. In this panoramic view note in particular the prominence and redness of the conus part of the vocal cords (indicated by white lines).

Croup, aka laryngotracheitis (2 of 4)

Closer view. Dotted lines signify normal airway diameter.

Croup, aka laryngotracheitis (3 of 4)

Even closer view showing redness and narrowing of the posterior subglottic airway.

Croup, aka laryngotracheitis (4 of 4)

View within the posterior subglottic narrowing.
  1. Meyer, Anna. “197. Pediatric Infectious Disease” Cummings Otolaryngology Head and Neck Surgery. Ed. Paul Flint. 6th ed. Vol. 3. Philadelphia, PA: Elsevier, 2015. 3045-3054.[]


Chondroma is a benign growth composed of cartilage cells.

Chondroma of Thyroid Cartilage

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CT scan of the larynx (1 of 4)

CT scan of the larynx, showing the thyroid cartilage (outlined by gray dotted lines) and an abnormality deforming the thyroid cartilage on one side (between the white arrows). Note how the thyroid cartilage bulges on that side, as compared with the opposite side, and the black speck which indicates varying densities in the cartilage.

Endoscopic View of the Larynx (2 of 4)

Same patient, endoscopic view of the larynx, again showing the abnormality (at arrows). Here the abnormality looks similar to a saccular cyst, but the scan (and subsequent biopsy) shows that it is cartilaginous and a chondroma, not chondrosarcoma.

Chondroma of thyroid cartilage (3 of 4)

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

Left Vocal Cord Sits Lower Then the Right (4 of 4)

Under strobe lighting, which shows that the left vocal cord (right of photo) is apparently at a lower level than the opposite cord.