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Textbook of

Official Publication of the Association of Phonosurgeons of India
Textbook of
Official Publication of the Association of Phonosurgeons of India

Nupur Kapoor Nerurkar MBBS MS (ENT) DORL
Laryngologist and Voice Surgeon
Laryngology Fellowship Program
DNB Co-ordinator
Department of ENT
Bombay Hospital and Medical Research Center
Mumbai, Maharashtra, India

Amitabha Roychoudhury MBBS DLO (Hons)
                          DNB (Otolaryngol) DLORCS (London)
Professor and Head
Department of ENT
Vivekananda Institute of Medical Sciences
Kolkata, West Bengal, India

Peak Woo MD FACS

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Textbook of Laryngology

First Edition: 2017

ISBN 978-93-86322-44-9
Dedicated to
My husband Rajeev and my daughters Kanika and Anaaya—the true joy!
My Laryngology colleagues, who have been truly generous in sharing their wisdom.

Nupur Kapoor Nerurkar

Dedicated to
My parents for their inspiration and guidance to pursue my dream
And my wife and my sisters for their encouragement throughout.

Amitabha Roychoudhury

Eric Barbarite BS Renuka Bradoo MS(ENT) DORL Frederik G Dikkers MD PhD

Pursuing MD Professor and Head Professor and Chairman
University of Miami Miller Department of ENT and Department of Otolaryngology and
School of Medicine Head Neck Surgery Head and Neck Surgery
Miami, Florida, USA Lokmanya Tilak Municipal Medical Academic Medical Center
College and General Hospital University of Amsterdam
Peter C Baxter MD Mumbai, Maharashtra, India Amsterdam, The Netherlands
Ear Nose and Throat— Dinesh K Chhetri MD D Gregory Farwell MD FACS
Head and Neck Surgery  Professor Professor and Vice Chairman for
Kaiser Permanente Department of Head and Neck Surgery Academic Affairs
Los Angeles Medical Center University of California Director of Head and Neck Oncology and
Los Angeles, California, USA Los Angeles, California, USA Microvascular Surgery
Vice Chief of Staff
Arnaud F Bewley MD Mark S Courey MD UC Davis Medical Center
Assistant Professor Professor of Otolaryngology Department of Otolaryngology—
Head and Neck Oncologic Surgery Department of Otolaryngology— Head and Neck Surgery
Microvascular Reconstruction Head and Neck Surgery University of California
Department of Otolaryngology— Vice-Chairman of Quality Davis, California, USA
Head and Neck Surgery Director
University of California Eugen Grabscheid Voice Center
Ramon Arturo Franco Jr MD
Davis Medical Center Division Chief of Laryngology—
Associate Professor
Sacramento, California, USA Mount Sinai Health System
New York City, New York, USA Department of Otolaryngology
Abir K Bhattacharyya MS DNB FACS Harvard Medical School
FRCS(Eng) FRCS(ORL-HNS) Boston, Massachusetts, USA
Rakesh Datta MS(ENT)
Consultant ENT Surgeon and Visiting Scientist
Professor, Department of ENT and
Deputy Director of Medical Education Laboratory of Complex and
Head and Neck Surgery
Whipps Cross University Hospital Armed Forces Medical College  Genetic Diseases
Barts Health NHS Trust Pune, Maharashtra, India Harvard TH Chan School of
London, UK Public Health
Shalaka N Dighe MS(ENT) DNB Boston, Massachusetts, USA
Bhagyashree Bokare MS DNB(ENT) DORL MBBS Division of Laryngology
Associate Professor  Fellowship in Laryngology Medical Director, Voice & Speech Lab
Department of ENT ENT Consultant Director of the Laryngology Fellowship
Government Medical College Zen Multispecialty Hospital Massachusetts Eye and Ear Infirmary
Nagpur, Maharashtra, India Mumbai, Maharashtra, India Boston, Massachusetts, USA
viii Textbook of Laryngology

John W Frederick MD Anagha A Joshi MS(ENT) DNB Gautham Kulamarva MBBS DORL
Resident Physician DORL FICS MS(ENT) DNB DOHNS(London)
MRCS (Edinburgh)
Department of Head and Neck Surgery Associate Professor 
Consultant ENT Surgeon
University of California Department of ENT
Maithri Speciality Clinics, Bendoorwell
Los Angeles, California, USA  LTMG Hospital and
Mangaluru, Karnataka, India
LTM Medical College
Soumitra Ghosh DLO DNB Sion, Mumbai, Maharashtra, India Jayakumar R Menon MS DNB FRCS DLO
Associate Professor
Senior Consultant
Department of ENT and Gauri Kapre MBBS MS(ENT) Department of Laryngology
Head and Neck Surgery Consultant ENT Surgeon Kerala Institute of Medical Sciences
Vivekananda Institute of Medical Neeti Clinics Thiruvananthapuram, Kerala, India
Sciences Nagpur, Maharashtra, India
Ramakrishna Mission Seva Pratishthan Unnikrishnan K Menon MS DNB(ENT)
Kolkata, West Bengal, India Associate Professor
William E Karle MD
Amrita Institute of Medical Sciences and
KK  Handa MS DNB Resident Physician
Research Centre
Director and Head Department of Otolaryngology—
Amrita Vishwa Vidyapeetham
Department of ENT and Head and Neck Surgery
Kochi, Kerala, India
Head Neck Surgery New York Eye and Ear Infirmary of
Medanta Medicity Mount Sinai Hassan Mohammed MBBS
Gurgaon, Haryana, India New York City, New York, USA FRCS(ORL-HNS) MSc
Specialists Registrar in Otolaryngology
Bachi T Hathiram MS(ENT) DORL Farha Naaz Kazi MBBS MS ENT North East Deanery, London, UK
DNB(ENT) Laryngology Fellow
Professor and Head Bombay Hospital and Sharat Mohan BSc MBBS MS DLO
Department of ENT and Medical Research Center
ENT Surgeon and Laryngologist (Retd)
Head and Neck Surgery Mumbai, Maharashtra, India
Voice Centre at the Royal Derby
TN Medical College and
Hospital and Medical School
BYL Nair Charitable Hospital Vicky S Khattar MS(ENT) DNB(ENT) Derby, England, UK
Mumbai, Maharashtra, India Assistant Professor
Visiting ENT Consultant Department of ENT and PSN Murthy DLO MS(ENT) FICS
Sir HN Reliance Foundation Hospital and Head and Neck Surgery Principal and Professor
Research Centre TN Medical College and Department of ENT and
Prarthna Samaj, Girgaum Head and Neck Surgery
BYL Nair Charitable Hospital
Mumbai, Maharashtra, India Dr PSIMS & RF, Chinoutpalli
Mumbai, Maharashtra, India
Visiting ENT Consultant Visiting Senior Consultant
Manju E Issac DLO DNB(ENT) Department of ENT and
Sir HN Reliance Foundation Hospital
Associate Consultant Head and Neck Surgery
and Research Centre
Department of Laryngology Manipal Hospitals
Prarthna Samaj, Girgaum
Kerala Institute of Medical Sciences Vijayawada, Andhra Pradesh, India
Mumbai, Maharashtra, India
Thiruvananthapuram, Kerala, India
Nupur Kapoor Nerurkar MBBS MS(ENT)
Michael M Johns III MD Gautam Khaund MS (ENT) DORL
Director, USC Voice Center Chief ENT Consultant Laryngologist and Voice Surgeon
Director, Division of Laryngology Nightingale Hospital, Guwahati Director
Professor Head of ENT Department Laryngology Fellowship Program
Department of Otolaryngology— Pratiksha Hospital, Guwahati DNB Co-ordinator, Department of ENT
Head and Neck Surgery Visiting Consultant Bombay Hospital and Medical
University of Southern California Apollo (International) Hospital Research Center
Los Angeles, California, USA Guwahati, Assam, India Mumbai, Maharashtra, India
Contributors ix

Swetha Pedaprolu MS DNB(ENT) Amitabha Roychoudhury MBBS Neha Sood DNB(ENT) MNAMS
Assistant Professor of ENT and DLO(Hons) DNB(Otolaryngol) Senior Consultant 
Head and Neck Surgery Department of ENT and
Dr Pinnamaneni Siddhartha Institute Professor and Head Head and Neck Surgery
of Medical Sciences and Research Department of ENT BLK Super Speciality Hospital 
Foundation Vivekananda Institute of Medical New Delhi, India 
Chinnoutapalli, Gannavaram Mandal Sciences
Krishna District, Andhra Pradesh, India Kolkata, West Bengal, India  Sanjay Subbaiah MS(ENT)
Fellowship in Laryngology
Pookamala Sathasivam MS DNB Specialist in Voice and
Michael J Pitman MD
Senior Lecturer Swallowing Disorders, MS ENT Centre
Department of ENT Bengaluru, Karnataka, India
Division of Laryngology
Department of Otolaryngology— Insaniah University College (KUIN)
Alok Thakar MS DNB DLO FRCSed
Head and Neck Surgery Kuala Ketil, Kedah, Malaysia Professor of Otolaryngology and
Columbia University Medical Center Head and Neck Surgery 
New York Presbyterian Sonali  H Shah DNB DMRD All India Institute of Medical Sciences
New York City, New York, USA Assistant Professor New Delhi, India
Department of CT and MRI
Vyas MN Prasad BA MSc DIC DLO Bombay Hospital and Medical Krishnakumar Thankappan MS DNB
FRCS(ORL-HNS) Research Center MCh
Fellowship in Laryngology Marine lines Professor
Consultant Otolaryngologist and Mumbai, Maharashtra, India Head and Neck Surgery and Oncology
Head and Neck Surgeon  Amrita Institute of Medical Sciences
NG Teng Fong General Hospital, Travis L Shiba MD Kochi, Kerala, India
Singapore  Laryngology Fellow
James P Thomas MD
Department of Head and Neck Surgery
WVBS Ramalingam MS(ENT) University of California
Professor and Director  Los Angeles, California, USA Portland, Oregon, USA
Department of ENT and
Head and Neck Surgery Hagit Shoffel-Havakuk MD Phaniendra Kumar Valluri MBBS
BLK Super Speciality Hospital  Laryngology Fellow MS(ENT)
New Delhi, India USC Voice Center Prof. Emeritus ENT
Department of Otolaryngology— Guntur Medical college
Marc Remacle MD PhD Head and Neck Surgery  Director, Sri Sathya Sai Institute of ENT
Professor University of Southern California and Research Center for Voice Disorders
Voice and Swallowing Disorders Los Angeles, California, USA Guntur, Andhra Pradesh, India
Department of Otorhinolaryngology—
Kate Young BAppSci(SLP) Hons FRCSLT
Head and Neck surgery, CHL-Eich Sunita Chhapola Shukla MS(ENT)
Clinical Lead Speech and Language
Luxembourg City, Luxembourg DNB FCPS DORL
Therapist Voice/Head and Neck/
Senior ENT Surgeon
Dysphagia, Derby Voice Clinic
David E Rosow MD FACS Mumbai Port Trust Hospital
Head and Neck Department
Assistant Professor of Otolaryngology Mumbai, Maharashtra, India
Royal Derby Hospital
University of Miami Miller Derby, England, UK
School of Medicine Shraddha Singh MS DNB(ENT)
Assistant Professor of Assistant Professor  Henry Zhang BMedSci MBBS MRCS
Clinical Vocal Performance Department of ENT  DOHNS
University of Miami Government Medical College and Specialty Registrar in Otolaryngology
Frost School of Music Hospital London Deanery, North Thames Rotation
Miami, Florida, USA Nagpur, Maharashtra, India  London, UK

Textbook of Laryngology, edited by Dr Nupur Kapoor Nerurkar and Dr Amitabha Roychoudhury, brings forward a
textbook that is quite unique in the need for a relevant, state-of-the-art and expert-driven text on laryngology for the
laryngologists and general otolaryngologists.
Dramatic advances in laryngology over the last 40 years have made larger textbooks that cover general otolaryn-
gology, largely obsolete for the study of laryngeal disorders. Earlier, the state of the art in diagnosis and management
of voice, swallow and airway disorders included subjects and approaches that would be unthinkable and were not
addressed in the standard otolaryngology textbooks written for the general otolaryngologists. Today, laryngology is a
recognized subspecialty. In the literature, we have seen a steady rise of laryngology papers submitted for review.
According to NIH PubMed, in 1976, there were 15 articles on the search topic of vocal fold paralysis, and in 2015, there
were 115 citations with the same search word. Such is one example of the proliferation of papers related to laryngeal
disorders. From diagnostics to therapeutics, dramatic advances continue to pace the changes that are evolving
dramatically in the specialty of laryngology. This is because quality-of-life issues related to voice, swallow, and airway
continue to drive the need for expertise care in one of the most treasured of our senses, contributing to high-quality life,
i.e. the need for excellence in voice, airway and swallow.
The topics and organization are comprehensive and detailed. From basic science to the future, the topics outlined
are of utmost urgency in international forums in laryngology that I have had the privilege to participate in. Topics such
as office diagnosis, new lasers, office procedures, new phonosurgery approaches, laryngeal reinnervation and robotic
surgery are some examples of the state of the art in laryngology. This carefully edited textbook addresses each topic in
A particular strength in the text is the broad focus on voice, airway and swallow issues related to laryngeal
function. From treatment of voice disorders for gender reassignment to surgery for laryngeal-tracheal stenosis, the editors,
Dr Nupur Kapoor Nerurkar and Dr Amitabha Roychoudhury have brought together an international group of experts
in the specialty of laryngology to address each topic. Many of the experts are the leaders in the inception and the
development of the treatment approaches in their chapters. Especially enticing are the chapters written by the experts
from Europe, USA and India, making this a truly expert collection of chapters that contributes to the English literature
in our specialty.
The editors and the contributing authors have in this collection a compendium of vital information that will be
a reference tool for both the practicing laryngologists and those practitioners of otolaryngology who seek to have an
up-to-date text on laryngology. For a novice, who is contemplating the subspecialty of laryngology, this textbook will
serve as a ‘Bible’ for years to come.

Peak Woo MD FACS

Clinical Professor of Otolaryngology
Icahn School of Medicine
New York City, New York, USA

“The human voice is the most beautiful instrument of all, but it is the most difficult to play.”
Richard Strauss (German Romantic Composer)

Over the past century, Laryngology has mushroomed to become a major specialty in medicine. Beginning with Manuel
Garcia’s discovery of mirror examination of his own larynx, diagnostics have today come a long way indeed.
The human larynx and mechanism of voice production, both in health and disease, have posed great challenges to
the clinicians over centuries. The 21st century has witnessed an exponential rise in voice disorders, probably an echo
of today’s ever-increasing vocal demands in every walk of life. Despite extensive research by anatomists, physiologists,
otolaryngologists and speech pathologists, and continued technological advancements across the globe, many
conditions in laryngology remain enigmatic. The specialty of laryngology has further expanded with the incorporation
of swallowing and airway disorders into its domain.
Indian laryngology has also grown by leaps and bounds over the past two decades, in tandem with the global
scenario. This textbook of laryngology, published under the aegis of ‘The Association of Phonosurgeons of India’, is
intended to be a comprehensive study material for any clinician pursuing practice and research in laryngology. It is also
intended to serve as a ready-reckoner for a voice pathologist.
We sincerely thank Dr Peak Woo for writing the Foreword of our textbook. We would like to place on record our
gratitude to Jaypee Brothers Medical Publishers (P) Ltd. and all our authors, who have worked tirelessly so that this
textbook could be born in nine months from the conception of the idea!

Nupur Kapoor Nerurkar

Amitabha Roychoudhury

We would like to acknowledge:

The founders of the Association of Phonosurgeons of India for their vision;

Jaypee Publishers, who first pursued and then supported us wholeheartedly;
Our teachers, who sowed the seeds of knowledge within us; and
Our distinguished contributors, without whom this book would have remained a dream.

Nupur Kapoor Nerurkar

Amitabha Roychoudhury

Section 1: History and Basic Sciences

1. A Historical Review of Laryngology 3

Unnikrishnan K Menon
2. Anatomy of the Larynx 13
Gauri Kapre, Nupur Kapoor Nerurkar
3. Physiology of Phonation 24
Sunita Chhapola Shukla, Nupur Kapoor Nerurkar
4. Physiology of Swallowing 31
Bhagyashree Bokare, Shraddha Singh

Section 2: Clinical Assessment and Office Procedures

5. Clinical Evaluation in a Patient with a Voice Disorder 61

James P Thomas
6. Stroboscopy, High-Speed Imaging, Videokymography and
Optical ­Coherence Tomography 68
Soumitra Ghosh
7. Voice Analysis and Therapy Planning by an SLP 76
Kate Young
8. Clinical Evaluation in a Patient with Dysphagia with Role of FEESST, VFS and TNE 86
Jayakumar R Menon, Manju E Issac
9. Imaging of the Larynx 93
Sonali H Shah
10. Injection Laryngoplasty 114
Nupur Kapoor Nerurkar, Farha Naaz Kazi
11. Office-Based Vocal Fold Procedures 124
Phaniendra Kumar Valluri
12. Laryngeal Electromyography in Spasmodic Dysphonia and
Overview of Spasmodic Dysphonia 130
Eric Barbarite, David E Rosow

Section 3: Phonosurgery

13. Principles and Essentials of Phonomicrosurgery 139

Peter C Baxter, Mark S Courey
xviii Textbook of Laryngology

14. Nodules and Polyps 147

Amitabha Roychoudhury
15. Cysts, Sulci and Mucosal Bridge 155
Nupur Kapoor Nerurkar
16. Lasers in Phonomicrosurgery 171
Nupur Kapoor Nerurkar, Shalaka N Dighe
17. Lasers in Early Glottic Cancer 185
Vyas MN Prasad, Marc Remacle
18. Principles of Laryngeal Framework Surgery 200
Gautam Khaund
19. Unilateral Vocal Fold Paralysis and Medialization Laryngoplasty 204
Hagit Shoffel-Havakuk, Michael M Johns III
20. Surgical Treatment of Spasmodic Dysphonia 215
KK Handa
21. Puberphonia and Relaxation Laryngoplasty 219
Sanjay Subbaiah
22. Feminizing Laryngoplasty 222
James P Thomas
23. Recurrent Respiratory Papillomatosis and Narrow Band Imaging 230
Frederik G Dikkers
24. Glottic Web 237
John W Frederick, Travis L Shiba, Dinesh K Chhetri
25. Considerations in the Professional Voice User 245
Henry Zhang, Hassan Mohammed, Abir K Bhattacharyya

Section 4: Inflammatory, Endocrine and Functional Voice Disorders

26. Localized Inflammatory and Infective Laryngeal Disorders 255

PSN Murthy, Swetha Pedaprolu
27. Systemic Inflammatory Disorders 268
Ramon Arturo Franco Jr
28. Laryngopharyngeal Reflux Disease 277
WVBS Ramalingam, Rakesh Datta, Neha Sood
29. Endocrine and Neurological Disorders 285
Sharat Mohan
30. Muscle Tension Dysphonia 290
Amitabha Roychoudhury

Section 5: Airway and Swallowing

31. Assessment of a Stridulous Patient 301

Renuka Bradoo
32. Pediatric Airway—An Overview 310
Gautham Kulamarva
Contents xix

33. Bilateral Vocal Fold Paralysis 318

Anagha A Joshi
34. Principles of Management of Laryngotracheal Stenosis 329
Alok Thakar, Pookamala Sathasivam
35. Laryngeal Trauma 340
Bachi T Hathiram, Vicky S Khattar
36. Surgical Management of Dysphagia 348
Jayakumar R Menon

Section 6: Recent Advances

37. Laryngeal Transplantation 357

Arnaud F Bewley, D Gregory Farwell
38. Transoral Robotic Surgery in Larynx and Hypopharynx 364
Krishnakumar Thankappan
39. Vocal Fold Regeneration 372
William E Karle, Michael J Pitman

Index 379
History and Basic Sciences
1. A Historical Review of Laryngology
2. Anatomy of the Larynx
3. Physiology of Phonation
4. Physiology of Swallowing

A Historical Review
of Laryngology

Unnikrishnan K Menon

"The more you know about the past, the better prepared and 100 BCE). 1 These were followed by the significant con-
you are for the future." tributions from Claudius Galen (2nd century CE) and Ibn
-Theodore Roosevelt Sina (Avicenna) (10th centuzy CE). The former has been pro-
claimed as the "Father ofba!Yl!gology''.2
As students of mediciine, we are well aware of the
INTRODUCTION importance of diagrams and illustrations in anatomy.
Larynx: the "voice box''. Laryngology: the study of this Needless to say, the Renaissance period in Europe made
beautifully complex organ. These are facts that the present a contribution to laryngology also. Leonardo da Vinci and
day ENT fraternity takes for granted. However, it has taken Michelangely erformed cadaveric dissections, followed
up by illustrations and detailed descriptions of laryngeal
a voyage of discovery to reach these obvious conclusions.
function. Casserius, in his book titled "The Anatomy of
Many famous names have contributed their ingenuity and
Voi<le and Hearing" (1600), gave detailed artistic descrip-
efforts to the development of this field. This chapter is a brief
tions of the larynx, that are reportedly very accurate (Fig. 1).3
look at those magnificent men and their contributions.
Ferrein, in 1741, gave us the term "vocal cords'; com-
When we think of the larynx, intuitively, we have the
paring them to the cords of a violin, activated by contact
"internal" view in mind, viz. the vocal fol s, glottis, etc.
with air column. The new name was promptly countered
That was not always the case. The external approach to
and view of the larynx predates the endoscopic view by a
long margin. This could be seen as one way of classifying
the history of laryngology-first, its discovery as a distinct
organ and later, the history of laryngoscopy. Leading on
from these would be the history of detailed studies of the
vocal folds and the development of laryngeal surgery and

Early Days

"The beginning is the most important part of the work."


Awareness of the larynx as a separate organ and its prob-

able role in voice production seems to have existed since
time immemorial. The many familiar names that come up in Fig. 1: Cover page of the book "The Anatomy of Voice and Hear-
various literature sources include Aristotle (350 BCE), cred- ing" by Casserius (1600).
ited with the first mention of the larynx in his book "Historia Acknowledgment: UCL Ear Institute and Action on Hearing Loss
Animaliuni; and Sushruta and Charaka from India (300 BCE Libraries.
4 Section 1: History and Basic Sciences

Fig. 3: Manuel Garica doing indirect laryngoscopy.

Fig. 2: Dr Benjamin Guy Babington, inventor of Glottiscope. Source: Garcia M. Traité complet de l’Art du Chant, 8th edition.
Source: By unknown. Available at Paris: Heugel et Cie; 1884.
dexplus/image/L0033903.html, CC BY 4.0, Author: Manuel Patricio Rodríguez García (* 17. März 1805 in Zafra, Katalonien, † 1. Juli 1906 in London).

by Bertin, who, in 1745, correctly described them as “vocal trainer Manuel Garcia’s excellent control of his own gag
folds”.1 As it has often been the case in medicine, the for- reflex! That, and his commitment to documentation and
mer name stuck. publication. Although the story is well described in various
sources and well known to most ENT surgeons, it bears
Laryngoscopy repetition in the present context. A pan-European per-
sonality (Spanish by birth, practiced in France and later,
“Who looks outside, dreams; who looks inside, awakes.” England), Manuel Patricio Rodriguez García was intent
—Carl Jung on examining the organ that gave rise to the voice, in his
capacity as a vocal music teacher. It was in September
The great import of the development of mirror laryngoscopy
1854 while walking down a road in Paris and seeing sun-
lay in the fact of it being the first time that an internal organ
light reflected from a window, that the idea came to him
could be examined, as it functioned, in a living person! all of a sudden: “I saw the two mirrors of the laryngoscope
One of the doyens of laryngology, Sir Morell Macken- in their respective positions, as if actually present before my
zie has traced the path of evolution of the “scope” from eyes.” He promptly purchased a dental mirror and a larger
Roman times, in his book, “The Use of the Laryngoscope hand-held mirror and proceeded to observe his own vocal
in Diseases of Throat”. M Levret (1743) and Bozzini (1807) cords in reflected sunlight. Thus, this non-medical person
are the two early pioneers of endoscopy.4 The latter can be successfully witnessed the abducting and adducting vocal
credited for first use of an external light source (reflected cords in breathing and phonation. He presented a paper
candle light) to look into a bodily cavity. A far brighter on “Observations on the Human Voice” before the Royal
light source, viz. sunlight, was used by Dr Benjamin Guy Society of London on May 24, 1855.5 He also gave a full
Babington (Fig. 2) in 1828, for his device to view the larynx. account of his findings in an address before the Seventh
It consisted of a double-mirror and tongue-retractor, and Session of the International Congress of Medicine in Lon-
has the rightful claim to be the first actual laryngoscope, don in 1881 (Fig. 3).6
which he called the Glottiscope. However, this and its Enter the medical men: Dr Ludwig Türck (1857)
modifications during the next few years, suffered from a (Fig. 4), a neurologist with interest in laryngology from
lack of clear description of findings, especially of the vocal Vienna and Dr Johann Czermak (1858) (Fig. 5), a physio­
cords, and clinical application. logist from Budapest. Both laid claims to active clinical
It would probably be correct to say that what led to use of the laryngoscope. This led to the infamous “Turkish
the “Eureka moment” in laryngoscopy was the singing war”, which lasted for approximately a decade. To
Chapter 1: A Historical Review of Laryngology 5

Fig. 4: Ludwig Türck. Fig. 5: Johann Czermak.

Source: By unknown. Reprinted in: Schmahmann JD, Nitsch RM, Source: By unknown. Available at
Pandya DN. The mysterious relocation of the bundle of Türck. B05755, Public Domain,
Brain: a journal of neurology: 1911–24, Public domain, https:// php?curid=19109424.

Fig. 6: Leopold von Schrotter. Fig. 7: Sir Morell Mackenzie.

Source: By unknown. Available at Source: By Walery. Available at
aeiou.encyclop.s/s377457.htm, Public Domain, https://commons. plus/image/V0026773.html, CC BY 4.0, https://commons.wikime-

Czermak must go the credit of taking sunlight out of cord lesions. The present day “office procedure laryngos-
the equation, having experimented with using artifi- copy” had already begun, nearly 40 years prior to the era
cial lighting for the examination within the walls of his of direct laryngoscopy.
clinic. Mirror laryngoscopy was no longer a “summer It would be remiss not to mention the name of Sir
pastime” in Europe! Morell Mackenzie (Fig. 7), the British laryngologist,
1870 witnessed the establishment of the first clinic who did pioneering work in the field. The first edition
of laryngoscopy in the Vienna General Hospital, headed of his path-breaking book “The Use of the Laryngo-
by Leopold von Schrotter (Fig. 6).3 Not only examination, scope in Diseases of the Throat” was first published in
but also procedures began in the form of excision of vocal 1865. It quickly went into multiple editions and reprints.
6 Section 1: History and Basic Sciences

Fig. 8: Chevalier Jackson. Fig. 9: Phenakistoscope.

Source: From Wikimedia Commons ( Source:
jpg Gallery:
24.html). would be out the scope of this chapter. However, the story
of the development of VLSS merits a brief description here.
In 1832, Joseph Plateau of Belgium invented the
Mackenzie was also a great teacher who trained many
“Phenakistoscope” (Greek for deceptive view) (Fig. 9). Its
foreign fellows. Overall, the effect was to establish laryngo­
early use was as a form of visual entertainment. Simon
logy as a full-fledged speciality, and a distinct medical and
von Stampfer from Austria renamed it the “Stroboscope”
surgical discipline in Europe and America, by the latter
(Greek for whirling view). And, in 1876–8, Max Joseph
half of the 19th century. National laryngology societies
Oertel, in Germany, tested its use to observe the vibrating
were founded in the United States of America (USA), few
vocal folds and to study voice production. Its description
European countries and Japan during this period. The First
was published in 1895.3 It was too cumbersome to use,
International Congress of Laryngology took place in Milan
but the Oertel laryngostroboscope existed in many clinics
in 1880 and was attended by 122 laryngologists.3
till the 1940s. Meanwhile, in 1931, an electrical engineer
The natural progression in the field would be direct
in the USA, Harold Edgerton, came up with an electronic
laryngoscopy. This took another 40 years, the dura- strobe light stroboscope, which gave rise to the present
tion being a result of the unavailability of adequate light invaluable tool.
sources. Kirstein, Killian, Chevalier Jackson—these three Farnsworth, in 1938, conducted the first documented
names remain etched on the firmament of direct laryngos- investigations of slow motion capture of the vocal folds
copy. The former published the first description of a direct using a high-speed motion picture camera. Using two mir-
laryngoscope (autoscope) in 1895, and lays rightful claim rors and an incandescent lamp, he achieved a sampling
as the “Father of Direct Laryngoscopy”. Killian devised rate of 4,000 pictures per second. However, clinical use was
the suspension laryngoscopy technique in 1911. And, the not practical as it involved manual frame-by-frame analy-
latter (Fig. 8), in Philadelphia, established the modern sis of huge amount of film reels. Švec and Schutte, in 1996,
techniques and principles of laryngoscopy and broncho­ developed the alternative high-speed imaging technique
scopy. of videokymography, combining standard video camera
Laryngologists were not yet done looking at and technology with estimates of vocal fold vibratory cycles.7
evaluating the larynx and the vocal folds. Innovations in Enter Harold Hopkins who began experimenting with
illumination, magnification and technology led to the the tensile strength, transparency, and homogeneity of
development of flexible (per-nasal) laryngoscopy, video- glass to construct long, flexible fibers that could carry light.
laryngostroboscopy (VLSS), videokymography (VKG) and Flexible endoscopy thus came into being in 1954. Hopkins
high speed glottis photography (HSP). The details of these patented his system in 1959, which Karl Storz company
Chapter 1: A Historical Review of Laryngology 7

bought in 1967. The result was a revolution in endoscopic sound, remarkably similar to the lung, tracheobronchial
illumination and imaging. In 1968, Sawashima and colle­ tree and vocal cords in humans.3
agues reported the first laryngeal images captured with Hoarseness, due to vocal overuse and abuse in profe­
transnasal flexible scopes.7 “Chip on tip” technology, ssional voice users, was noted even before the present
developed in 1993, having the camera sensor at the end industrial—technological era. The victims in those days
of the flexible scope, further revolutionized laryngoscopy. were travelling preachers (clerics) who were burdened
High speed videoendoscopy (HSV), digital kymography with the task of giving long sermons in smoky environ-
(DKG), dynamic optical coherence tomography (OCT) ments (candle-lit halls). This came to be termed “dysphonia
and narrow band imaging (NBI) are all newer entrants clericorum”, described in detail in a book by that name by
either in early stages of clinical use or available in research James Mackness in 1848.3 Management modalities for the
facilities. same were described in a popular text, “The Hygiene of the
The last stop in the story of laryngoscopy would be the Vocal Cords”, by the British doyen, Morell Mackenzie (first
use of the microscope for laryngeal procedures. The first published in 1886).
name in this regard would be Prof Rosemarie Albrecht from Voice and speech were considered as medical disci-
Erfurt, Germany, who, in 1954, modified the colposcope plines in Europe. A landmark publication was brought out
and combined it with the microscope to get a magnified by Luschinger and Arnold in this subject in 1949.3 The lat-
view of the vocal cords.2 These attempts were fine-tuned ter, Godfrey E Arnold, is another name to reckon with in
and formalized by the Austrian Prof. Oskar Kleinsasser. the annals of laryngology. He was both medical doctor and
He modified the direct laryngoscope so as to facilitate a trained pianist from Vienna, who went onto become the
both binocular vision and use of both hands. This was head of research at the New York Eye and Ear Infirmary. It
followed up by addition of the Zeiss microscope in 1962. would be intuitive to think of the laryngologist being good
Microlaryngoscopy thus arrived, heralded by Kleinsasser.2 in the musical fields. This meeting of Science and Art has
arguably been taken to its zenith by Prof Robert T Sataloff.
Voice Besides being an authority on the topic of professional
voice,8 he has multiple degrees in the subject of Music.
“The human voice is the most beautiful instrument of all, Meanwhile, in the USA, speech language pathology
but it is the most difficult to play.” developed into a nonmedical specialty attracting far more
—Richard Strauss members than otolaryngology. An important tool in voice
assessment, the voice handicap index (VHI) was created
In ancient Egypt, circa 3000 BC, the human voice was
and published in 1997.9
thought to be a magical phenomenon originating in the
lungs.2 One of the specific contributions listed in the name
of Claudius Galen is that he demonstrated that the brain
controls human voice. He has been mentioned as the
“True knowledge comes with deep understanding of a
“godfather of phoniatrics and Voice Science”.2 Avicenna
topic and its inner workings.”
(Ibn Sina, 980–1037), the multitalented and multifaceted
—Albert Einstein
Persian devoted an entire chapter to the production of
voice and its disturbances in his blockbuster medical text, Erasistratos, in the year 290 BC, is said to have described
“Canon of Medicine” (Al-Qanun fi al-Tibb), which was a the function of laryngeal muscles.1 In 1791, Andersch first
standard book in most European universities for up to 500 described laryngeal innervation in detail, followed by
years thence. Swan in 1830.3 Detailed functioning was outlined by Mayo
Gradually, as the relationship of the larynx and voice in his classic work “Outlines of human physiology” (1829).
began to be appreciated, there were also attempts to cre- By the mid-1830s, motor innervation was fully described
ate a mechanical “voice box”. Alberti reports a fascinating as well as the functioning of laryngeal muscles. Dutro-
description in a book by von Rempelen, “Mechanism of chet, in 1806, introduced the idea of vocal cords acting as
Human Speech Together with a Description of a Speaking a pair of passively vibrating reeds. This concept was taught
Machine” (1791). In it, he illustrated the arrangement of for generations, until Van de Berg, in 1958, came up with
bellows, a reed and shape-changing air passage to create his myoelastic theory of voice production.10 Von Luschka
8 Section 1: History and Basic Sciences

published a book on laryngeal anatomy in 1871.3 In 1878, Queen Victoria! He did a laryngoscopy and excised part of
during one of the meetings of the Clinical Society of Lon- the laryngeal growth in May 1887. The surgical specimen
don, Sir Felix Semon presented his theory explaining the was sent to the pathologist Virchow, who examined it and
sequence of the internal laryngeal muscle paralysis due to declared that it was not malignancy. Hence, laryngectomy
laryngeal nerve malfunction. Subsequently, he described was ruled out. Tracheostomy was done in January 1888.
his eponymous law in 1881. Isambert, in 1876, made In March, Frederich’s father, Emperor William I, died and
the distinction between pharynx and larynx as separate the aphonic new Emperor Frederich III moved to Berlin to
organs. In 1891, Hajek first detailed the lymphatic drain- ascend the throne. His clinical condition worsened; and he
age of the larynx. Much later, in 1964, Pressman furthered died 93 days after ascension. The misdiagnosis and unsuc-
this knowledge with the use of dyes and radioisotopes.11 cessful treatment caused a bitter disagreement between
Hirano Minoru brought about a paradigm shift in the the leading laryngologists, Mackenzie on one hand and
understanding of vocal fold physiology, and thereby sur- Sir Felix Semon (and most German laryngologists) on the
gical principles, with his landmark paper describing the other. And, it also resulted in innuendo about this laryn-
body-cover theory of vocal fold structure.12 Ingo Titze, a geal carcinoma being the cause of World War I! But, that
vocal scientist in the USA, did further work in the physi- would be for the history aficionados.
ology of vocal folds and phonation. In the mid-1990s, he The more uncommon tumors were also being
came up with a new term—Vocology.13 described. Heusinger, in 1822, reported the first case of
cartilaginous tumor of the larynx, followed by a detailed
Pathology series report by Irwin Moore.15 Mackenzie’s 1871 book
included the first ever description of laryngeal hemangi-
“Everything is pathology, except for indifference.” oma.16 Another rare tumor in the larynx, neurofibroma,
—Emil Cioran was first described by Suchanek in 1925.17
Laryngeal papilloma, especially the recurrent variety,
Infection was probably the most common, and serious, has been a consistent “thorn-in-the-flesh” for laryngolo-
issue in the early days, until the understanding of infec- gists. The entity was referred to as “warts in the throat” in
tious diseases and their treatment gained ground. Diph- the 17th century. Later, it was once again the laryngologist
theria, croup and tuberculosis dominated the spectrum of nonpareil, Morrel Mckenzie, who, in 1871, remarked upon
laryngeal pathologies. All through the late 18th and early the association of warts and laryngeal papilloma.18 In 1923,
19th century, books and treatises were written on these. Ullmann became the first to prove its viral etiology.19
Alberti cites the example of Ryland’s book (1837), in which Spasmodic dysphonia is a well-known entity amongst
a mere 8 pages out of 300-odd, were given to the descrip- laryngologists, although not so common in the overall
tion of neoplasms; the rest, concerned with “inflammatory spectrum of voice disorders. The awareness of this distinct
disease, external injuries and inhaled foreign bodies”.14 condition can be dated back to 1871 when Ludwig Traube
In 1871, Morell Mackenzie published his book “Essay on described “nervous hoarseness” in a young girl and called
Growths in the Larynx” which contained “reports and it spastic dysphonia. The present accepted term was given
analysis of 100 consecutive cases treated by the author”. by Aronson in 1968.20 Andrew Blitzer et al. (1985) classi-
Morgagni and Boerhave are thought to have described fied it as a dystonia of neurological origin. The eminent
Indian laryngologist, Dr Jayakumar Menon, described a
cases carcinoma of larynx in the 18th century.3 This con-
pathognomonic sign for abductor spasmodic dysphonia
dition achieved celebrity status, on account of its most
in 2011.21
famous victim in the 19th century. The well documented
sequence of events is briefly described here.
In January of 1887, the German Crown Prince Freder- Surgery
ich started to have dysphonia, initially attributed to a cold.
“A good surgeon is a doctor who can operate and knows
Inhalations and gargling were not useful, and his physi-
when not to operate.”
cian, Wegner, called Gerhardt, the famous laryngologist
—Theodor Kocher
from Berlin. Multiple treatment modalities did not help.
Second opinion arrived in the form of Sir Morrell Macken- At the outset, it must be stressed again that procedures on
zie from England, referred by the patient’s mother-in-law, the larynx began much before its interior was visualized.
Chapter 1: A Historical Review of Laryngology 9

use in the pharynx and larynx to Edmund Jelinek. The lat-

ter utilized this to remove a laryngeal polyp under local
anesthesia and reduce the pain of another patient with
laryngeal tuberculosis.3 With the advent of sufficiently
bright electric lamps in 1889, Rudolph Voltolini (Breslau,
Germany), performed some minor intralaryngeal oper-
ations.24 Chevalier Jackson was perhaps the first, in 1915,
to excise a tumor of the epiglottis through an endoscope
using cup forceps.25
In 1911, Wilhelm Brunings (Germany) first described
the procedure of injection laryngoplasty by injecting par-
affin into the paralyzed vocal fold. Polytetrafluoroethylene
(PTFE), accidentally discovered in 1938, and popularized
in the market as Teflon in 1945, was used by Arnold in 1962
Fig. 10: Horace Green performing blind orotracheal cannulation for the same purpose.26
of the larynx and trachea with a whalebone probang to administer
1963: The venue, a bar of the Roosevelt Hotel in New
topical silver nitrate to the diseased membranes of the airway.
Source: Dr Horace Green and His Method. Harper’s Weekly, Feb- York. Hans von Leden and Godfrey Arnold were discuss-
ruary 5, 1859. pp. 88–90. ing the role of surgery to enhance vocal function. Lo and
behold, a new term was coined—Phonosurgery! Klein-
sasser’s efforts, mentioned earlier as the harbinger of
This paradox of sorts was exemplified by Dr Horace Green,
microlaryngoscopy, bore fruit in 1968, in the form of an
of New York, who devised an instrument, the probang, to
epochal text on operative laryngology.
apply medications (silver nitrate) to the larynx (Fig. 10).
Laser was invented in 1958, and began to be used in
He reported his results in 1840 and published a treatise
ophthalmology first. The CO2 laser and its use in laryngol-
in 1846. Interestingly, neither work mentions the word
ogy happened in the 70s. Dr Geza Jako, a Hungarian doctor
“laryngoscopy”. Although initially ridiculed for his work,
settled in the USA, designed a series of MLS instruments.
he has since been considered the pioneer laryngologist of
He also revolutionized endoscopic laser surgery in the
the United States.22
1970s, and is recognized as the father of laser surgery in
Charles Ehrmann is reported to be the first (1844) to
laryngology.27 The next development has been the concept
“remove a laryngeal polyp”. Another name, not that fre-
quently encountered in the annals of laryngology, is that of of transoral laser microsurgery (TLM) for squamous cell
Victor von Bruns. He was a German surgeon, who in 1862, carcinoma of the larynx. Strong (1975), Vaughan (1978)
reported “bloodless enucleation of a laryngeal polyp”. The and, in the present, Steiner have helped to revolutionize
source citing these names has placed the latter as the pio- the procedure.
neer of laryngoscopic surgery.23 Payr, 1915, is credited with the first description of sur-
Whatever the merits of the above two reports, Vienna gery on the laryngeal framework to effect changes in vocal
General Hospital, by all available records, can lay claim to fold positioning. However, it did not catch the popular
the earliest series of laryngeal procedures. Leopold von imagination of laryngologists. Then, in 1974, from Kyoto
Schrotter (Fig. 6), head of the first ever laryngoscopy clinic University, Professor Emeritus Nobuhiko Isshiki rejuve-
(1870), became adept at the excision of laryngeal polyps, nated the procedure, classifying it and describing indica-
even without anesthesia. The issues of lighting and patient tions in detail. He popularized it and it bears his name—
compliance were dealt with in imaginative ways. The con- Isshiki thyroplasty.28
vex lens effect of a water-filled glass bowl, kerosene lamps, A surgical treatment modality for spasmodic dyspho-
gaslight—all found a place in the paraphernalia of laryn- nia, unilateral sectioning of the recurrent laryngeal nerve,
geal surgery! Preoperative work-up included self-training was first described by Herbert Dedo in 1976.29 Andrew
for the control of gag reflex by the patients.3 Blitzer described the use of intravocal fold injection of
Local anesthesia arrived, in the form of cocaine, used botulinum toxin in 1988. This is now the most accepted
by an ophthalmologist, Koller, in 1884. He suggested its treatment.30
10 Section 1: History and Basic Sciences

Microflap technique as a method of excision of benign the larynx was being excised for almost any sort of malig-
lesions of the vocal folds was based on Hirano’s body- nant growth in the vicinity. As a result, the procedure was
cover theory of phonation. It was first described in 1982, slowly earning a poor reputation. By 1910, many research-
followed by publication of experience with the technique, ers arrived at the conclusion that patients with laryngeal
by Sataloff, in 1986.31 carcinoma were likely to live longer without surgery.
Laryngectomy: The history of this significant surgical There were many in Europe and the Americans who
procedure would merit an entire chapter in itself. As such, were attempting partial laryngectomies. But, neither pro-
it is being described in a separate section. tocol nor detailed technique was published. Laryngofis-
The first laryngofissure for laryngeal cancer was sure remained the workhorse approach, with conflicting
reported by Gurdon Buck of New York in 1851. It needs claims of success and failure.
to borne in mind that this was before the onset of indirect Partial (vertical) laryngectomy was introduced by
laryngoscopy and anesthesia! The description of the pro- Billroth himself in 1878. As an interesting aside, it may
cedure by Buck is surely not for faint hearts.3 In those days, be noted that the first partial laryngectomy was reported
these (neck) surgeries were the exclusive province of the much earlier (circa mid-18th century), when a French
general surgeons. Sands (1865) and Solis Cohen (1867) surgeon performed median thyrotomy for foreign body
performed relatively more successful laryngofissure exci- removal!33 In 1913, Wilfred Trotter was the first to describe
sions of growths. These efforts were countered by Mackenzie, a practical approach to excision of supraglottic tumors.
who in 1871, published the result of 28 external proce- This was modified by Prof Justo Alonso, of Montevideo,
dures, documenting them to be worse than endoscopic Uruguay, 34 years later. This master can be considered the
treatment. However, in 1903, Semon reported from his father of the present-day horizontal (supraglottic) laryn-
own experience of 20 cases of laryngofissures in laryngeal gectomy.33 In his 1954 book “Laryngeal Cancer”, he lays
cancer, with or without removal of cartilage fragments, bare his motivation behind the procedure. In an inspira-
resulting in 17 recoveries, 2 recurrences, and 1 death.32 tional introduction, he wrote about his determination to
The father of German surgery, Langenbeck, and his “stop the war against the larynx, since its removal is unnec-
illustrious student, Theodore Billroth, were the first to essary and ineffective in many cases”. His stated motto was
devise the steps of total laryngectomy. And, on the last day to preserve the unaffected glottis and hence, the function
of the year 1873, Billroth performed the first ever success- of the larynx, thus helping the patient to return to society
ful laryngectomy in a case of laryngeal carcinoma. It must without significant handicap.34 The master was duly fol-
be mentioned here that the general improvement in surgi- lowed by students who carried the good work globally.
cal outcome was the result of three related developments Som (New York), Bocca (Milan) and Ogura (St. Louis) all
during the mid-19th century, viz. anesthesia, hemostatic propagated and popularized the procedure to its present
forceps’ use and infection prophylaxis. Billroth’s patient, status. Progressing into the present era, Pearson popular-
a young teacher, had not improved with the hitherto ized near-total laryngectomy in the 1980s.33
standard modalities of chemical cautery and laryngofissure. Concerns over the loss of function of this organ existed
His laryngectomy, which involved nonseparation of the from the beginning. In the very first laryngectomy itself,
pharynx and trachea, was described in detail. The doyen Billroth’s assistant Gussenbaeur devised and fitted an arti-
of thyroid and now, laryngeal surgery, was dutifully fol- ficial larynx.3 However, as at other junctures in the event-
lowed by others in the field, but unfortunately, not all met ful history, there are reports of earlier attempts. Czermak
with success. Aspiration pneumonia was the usual culprit. described the case of a young girl with complete laryngeal
The complete separation of the food and lower air passage stenosis who achieved speech using an artificial larynx to
thus became a felt need. The founder of laryngology in the divert air from the tracheostomy tube to hypopharyngeal
United States, Dr Jacob Da Silva Solis-Cohen, incorporated region. Returning to the postlaryngectomy situation, all
this step for the first time in 1884, with the patient surviv- through the late 19th century, many surgeons tried out
ing for 11 years. Later (1894), he also went on to document modified tracheostomy tubes as well as mechanical vibra-
the first successful use of esophageal speech.3 tors. Details can be found in a comprehensive write-up by
However, laryngectomy was still very much a work in Bien et al.35 The next step occurred in the 1920s with See-
progress. Indications, technique and types—all were in a man promoting the concept of esophageal voice. This held
state of flux. Over the last 2 decades of the 19th century, centerstage for many decades, despite several pioneering
Chapter 1: A Historical Review of Laryngology 11

attempts at fistulization between the airway and food pas-

sage. The arrival of a simple prosthesis heralded the pres-
ent ear of voice rehabilitation. In 1972, Mozolewski, from
Poland, devised a “home-made” valve to be implanted
into the fistula. This did not gain popularity. Finally, Singer
and Blom developed a tubular prosthesis with a duckbill
valve in 1979. Success with this was reported in 1980.36 This
has, by and large, remained the workhorse till the present
To complete the picture, a very quick look at the evolu-
tion of radiotherapy is in order. The discovery of radium and
X-rays, at the turn of the 19th century, was soon followed
by experimental use for cancers. This gained pace between
the two World Wars. However, surgery was numero uno
and radiation was seen as a last hope. Post-World War II Fig. 11: Theodore Billroth.
saw the advent of cobalt and then, high-energy “linacs”. Source: By Theodor-Billroth.jpg: Fotograf Erich Conrad derivative
These, combined with the subsequent imaging modalities work: Material scientist—This file was derived from Theodor-Bill-
roth.jpg:, Public Domain,
(CT and MRI), have led to near-perfect systems of delivery
of radiation to the cancer tissue. Thus, we are now in the
era of organ preservation for cases of laryngeal cancer.
■■ Surgery of the larynx has multidimensional aspects.
What lies ahead? Procedures with an external approach, especially lar-
yngofissure, were the early mainstays. Later, the endo-
“The best way to predict the future is to invent it.” scopic approach, especially microlaryngeal surgery,
—Alan Kay became the norm with Oskar Kleinsasser being its
It has been an exhilarating roller-coaster ride over the last harbinger. Laryngectomy for carcinoma was first suc-
couple of centuries in the field of laryngology. We may be cessfully described by the master surgeon, Theodore
in a plateau phase in the present era, but with progress in Billroth (Fig. 11). Jacob Solis-Cohen developed and
the area of biomedical technology and nanoscience, the popularized it in the USA. Phonosurgery, thyroplasty
possibilities are endless. The future beckons… and microflap technique are the new buzzwords in
voice surgery, based on the pioneering work of the
likes of Arnold, Hirano and Isshiki.
Synopsis ■■ Looking ahead, the modalities of laryngeal and voice
■■ Larynx as the organ of voice was being recognized evaluation look set to cross new frontiers, along with the
from the early days of Greek and Indian medicine. concept of organ preservation in the realm of surgery.
■■ The dawn of the modern era of laryngology can be
traced to the 1855 description of mirror laryngoscopy
by Manuel Garcia, earning him the title of “Father of
Laryngoscopy”. 1. Nogueira Júnior JF, Hermann DR, Américo RD, et al.
A brief history of otorhinolaryngolgy: otology, laryngology
■■ Many European and American laryngologists refined
and rhinology. Revista Brasileira de Otorrinolaringologia.
and popularized the procedure, Sir Morell Mackenzie 2007;73(5):693-703.
and Chevalier Jackson were the foremost amongst these. 2. Sataloff RT, Chowdhury F, Portnoy JE, et al. Surgical
Alfred Kirstein and Gustav Killian were the pioneers of Techniques in Otolaryngology—Head and Neck Surgery:
direct and suspension laryngoscopy respectively. Laryngeal Surgery. In: Sataloff RT (Ed). Chapter:
■■ Examination of the larynx and evaluation of the voice Introduction: The History, Evolution and Development of
Phonomicrosurgery. London: JP Medical Ltd; 2013. p. 3.
have developed by leaps and bounds in the last 70-odd
3. Alberti PW. The history of laryngology: a centennial cel-
years, thanks to advances in optics and biomedical ebration. Otolaryngology—Head and Neck Surgery.
technology. 1996;114(3):345-54.
12 Section 1: History and Basic Sciences

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5. Garcia M. Observations on the human voice. Proc R Soc 23. Banerjee DD. History of Medicine. New Delhi: B Jain
Lond. 1854-55;7:399-410. Publisher; 2004. p. 134.
6. Garcia M. On the Invention of the Laryngoscope. Transac­ 24. Feldmann H. The History of Diaphanoscopy. Pictures from
tions of the Seventh Session of the International Congress the History of Otorhinolaryngology, Highlighted by Exhibits
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7. Mehta DD, Hillman RE. The evolution of methods for imag- Laryngorhinootologie. 1998;77(5):297-304.
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16. Thomas RL. Non-epithelial tumours of the larynx. J
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21. Menon JR. Flaring of ala nasi: a reliable diagnostic sign for 36. Singer MI, Blom ED. An endoscopic technique for res-
abductor spasmodic dysphonia. Int J Phonosurg Laryngol. toration of voice after laryngectomy. Ann Otol Rhinol
2011;1:41-3. Laryngol. 1980;89(6):529-33.

Anatomy of the Larynx

Gauri Kapre, Nupur Kapoor Nerurkar

INTRODUCTION nerves respectively as their segmental innervation. The

human epiglottis, unrelated to the primitive branchial
The vast range of sounds produced by humans separates arches, is a unique mammalian addition.
them from other animals, thus giving them one of the major The fibrocartilaginous framework of the larynx sus-
advantages of communication with their fellows. Although, pended in the neck from the hyoid bone comprises carti-
each person has a specific "vocal signature" which dis- lages, ligaments, membranes, and muscles. The anterior
tinguishes his/her voice from others, the basic anatomical aspect of the arynx is quite superficial (making laryngeal
structure of the larynx remains the same in all. This is framewofR surgery easier) as compared to the posterior
because though the larynx, a phonating system, creates a aspect of the liil)'IlX, which is related to the laryngopharynx,
basic buzzing sound, it is the resonating system (the phar- pre ertebral fascia, and muscles, and to the bodies of
ynx, nose, and sinuses) which imparts a specific character cervical vertebrae 3 to 6. Laterally, the larynx is related
to each voice. The articulating systems (tongue, soft palate, to t e carotid sheath, infrahyoid muscles, sternomastoid
and lips) create the spoken word. However, phylogeneticall muscle, and the thyroid gland.
the most significant function of the larynx is its sphincteric The laryngeal anatomy can be studied under the follow-
action during deglutition, which allows a safe swallow with- ing heads:
out aspiration of food or water into the airway. ■ Cartilages
The larynx is divided into three zones: (1) the supra- ■ Muscles
glottis, (2) the glottis, and (3) the subglottis. Each of ■ Ligaments and membranes
these has unique anatomic features and specific clinical
importance. The supraglottis e tends from the laryngeal CARTILAGES
inlet to the ventricle. The glottis or the rima glottidis is
constituted by the true vocal folds, and the subglottis The laryngeal cartilages (Figs. IA and B) are classified as
extends from the true vocal folds to the lower border of "paired cartilages" and "unpaired cartilages''. The unpaired
the cricoid cartilage. The undersurface of the true vocal cartilages; thyroid, cricoid, and epiglottis, are the larger
folds is referred to as the infraglottic area. ones, whereas the paired cartilages: arytenoids, corniculate
During the 4th week of life, the respiratory tract and cuneiform cartilages, are smaller in comparison.
develops as an outgrowth from the primitive gut termed
as the tracheobronchial groove. The larynx itself develops Epiglottis
in two parts: (1) the supraglottis, arising from the buc- The first unpaired cartilage in the larynx is the epiglottis.
copharyngeal bud (fourth branchial arch); and the glottis This fibroelastic cartilage forms a leaf like protective
and subglottis from the tracheobronchial bud (fifth and covering over the laryngeal inlet (Fig. 2). It "flops" down
sixth branchial arch). The corresponding intrinsic mus- and approximates with the arytenoid cartilages to cover
cles are derived from the fourth and sixth branchial arch the glottic inlet during swallowing and prevents aspiration
and therefore carry the superior and recurrent laryngeal of food or water into the airway. In infants, the epiglottis
14 Section 1: History and Basic Sciences

Figs. 1A and B: Anterior and posterior views.

triangular space anterior to the epiglottis is the preepiglottic

space of Boyer. This space, which contains fat, is bounded
by the thyrohyoid membrane anteriorly, the infrahyoid epi­
glottis posteriorly, and the hyoepiglottic ligament supe­
riorly. When a primary laryngeal malignancy has infiltrated
into the space of Boyer through the infrahyoid epiglottis, it
is considered to be less sensitive to radiation alone.3

Thyroid Cartilage
The thyroid cartilage is the most prominent unpaired
cartilage of the larynx. The word “thyroid” is derived
from the Greek word “thyroidues”(shield) and is named
as such due to its shape. The thyroid cartilage (Fig. 3)
is made of two laminae which fuse in the midline. The
Fig. 2: Epiglottis. superior border bears a notch termed the “thyroid notch”.
This serves as an important landmark for many anterior
neck surge­ries. The two laminae meet in the midline at an
can be exaggeratedly folded upon itself giving it an “omega” angle of about 90° in males and 120° in females. This fusion
shape.1 This is distinctly seen in infants with laryngo­ creates a prominence in the neck anteriorly, the “Adam’s
malacia where the laryngeal inlet closes into a “fish-mouth” apple”. The angle being more acute in men makes the
appearance as the epiglottis gets sucked in during inspi­ male Adam’s apple more prominent in them. At its
ration giving rise to inspiratory stridor. The upper free end lateral ends, the cartilage has two long horn-like projections
of the epiglottis lying above the level of the hyoid bone is superiorly and inferiorly. These are termed the superior
called the suprahyoid epiglottis and the lower half is the and inferior cornua, respectively. The inferior projec­
infrahyoid epiglottis. This end is attached to the thyroid tions are shorter than the superior ones. The superior
cartilage by the thyroepiglottic ligament just above the cornua articulate with the hyoid bone and the inferior
anterior commissure of the glottis. The epiglottis has a cornua form a synovial joint with the cricoid cartilage.
lingual (anterior) and a laryngeal surface (posterior). There At the point where the superior cornu joins the thyroid
are several pit-like depressions over the posterior surface lamina, there is a prominence called the superior tubercle.
of the epiglottis which also have taste buds on it.2 The The superior laryngeal vessels and nerve pierce the
Chapter 2: Anatomy of the Larynx 15

Fig. 4: Cricoid cartilage, arytenoid cartilages, and corniculate

Fig. 3: Thyroid cartilage. ­cartilages.

thyrohyoid membrane 1 cm above this point to enter this is the narrowest part of the airway and even a minimal
the larynx. Along the inferior border is a small rounded amount of subglottic edema may result in significant
projection called “the inferior tubercle”. The broad lamina respiratory distress.6 The cricoid can be palpated anteriorly
has a slightly elevated line running from the superior in the neck and corresponds to the C6 vertebral level. The
tubercle obliquely to the midline inferiorly called the inferior border of the cricoid marks the end of the larynx
oblique line. The two strap muscles; sternothyroid and and commencement of the trachea. It also corresponds
thyrohyoid, attach anterior to the oblique line while the with the end of the pharynx and the beginning of the
inferior constrictor is attached posterior to it. The thyroid esophagus posteriorly. On its posterolateral surface is
cartilage is a hyaline type of cartilage which means it a facet where the inferior horn of the thyroid cartilage
can undergo endochondral ossification or calcification articulates in a synovial joint. This joint allows tilting move­
which can sometimes make it hard and radiologically ment of the thyroid cartilage. The superior surface of the
dense. Hence, in laryngeal framework surgeries which posterior cricoid lamina bears a facet on either side for the
require operating upon the thyroid cartilage, drilling may articulation of the arytenoid cartilage. This cricoarytenoid
at times be required.4 Knowledge of the relative position joint is also a synovial joint and allows rocking movement
of the internal laryngeal structures, particularly the vocal of the arytenoids over the cricoid which plays an important
folds, is important during planning framework surgeries, role during respiration and phonation.
­especially while making the window in type 1 thyroplasty.
The vocal folds lie closer to the inferior border of the Arytenoid Cartilages
thyroid cartilage, and not mid-way, as was previously
These are paired cartilages that articulate with the superior
surface of the posterior arch of the cricoid cartilage, on
either side of the midline. These are pyramid-shaped
Cricoid Cartilage cartilages with their apices superiorly, which support the
The third important unpaired cartilage of the larynx is the corniculate cartilages. The base of the arytenoid cartilages
cricoid cartilage (Fig. 4). It is classically described as “signet saddles the cricoid. This base has an anterior projection,
ring” shaped with a shorter anterior arch and a taller the vocal process to which is attached the vocal ligament
posterior lamina. It is the only cartilage in the laryngotra­ and a lateral muscular process which gives attachment
cheal system to completely encircle the airway, the rest to the intrinsic laryngeal muscles. The articulation of the
of the cartilages being deficient posteriorly. Since, the cricoid cartilage with the arytenoid allows movement
cricoid is a ring-shaped cartilage, the lumen of the larynx in multiple axes (Fig. 5). There is a significant degree
is fixed at this point and is adynamic. In an infant larynx, of mobility at the cricoarytenoid joint which imparts a
16 Section 1: History and Basic Sciences

Fig. 5: Movements at the cricoarytenoid joint. (X: Vocal process).

wide repertoire of movements to the arytenoids. These and aid in the elevation and depression of the larynx
include abduction, adduction, anterior-posterior sliding, during speech and swallowing.
and medial-lateral tilting. The result is that the vocal folds
do not merely open or close in a horizontal plane. During Intrinsic Muscles
abduction, the muscular process of the arytenoid gets
The intrinsic muscles can be grouped as adductors (3),
pulled about an oblique axis posteriorly, superiorly and
abductor (1), and tensor (1), depending on the change
laterally by the posterior cricoarytenoid muscle. The
they bring about in the vocal folds.
adductors (mainly the lateral cricoarytenoid) act upon the
The adductors are the lateral cricoarytenoid, the thyro­
arytenoid causing movement in a three-dimensional plane arytenoid, and the interarytenoid. The sole abductor is the
which makes the arytenoid rotate internally, by p ­ ulling posterior cricoarytenoid and the tensor is the cricothyroid.
the muscular process anteriorly, inferiorly and medially. All the intrinsic muscles of the larynx are supplied by the
Due to this complexity of actions, movement at the crico­ recurrent laryngeal nerve except the cricothyroid which is
arytenoid joints alters the distance between the vocal supplied by the external branch of the superior laryngeal
processes of the two arytenoids as well as between each nerve.
vocal process and the anterior commissure.
Lateral Cricoarytenoid
Corniculate and Cuneiform Cartilages
The lateral cricoarytenoid muscle (Fig. 6) is a paired
The corniculate cartilage sits on top of the arytenoid and ­muscle, i.e. one on each side. It extends from the anterior
moves along with the cricoarytenoid joint (see Fig. 4). part of the muscular process of the arytenoid to the
The cuneiform lies above the corniculate and lateral to the superior surface of the cricoid cartilage laterally. The
arytenoid and is completely embedded in the aryepi­glottic contraction of this muscle pulls the muscular process of the
fold. Both are small fibroelastic cartilages which presumably arytenoid anteromedially which results in a concomitant
provide additional support to the aryepiglottic folds. downward and medial rotation of the vocal process and
causes adduction and lengthening of the vocal folds.
Traditionally the muscles of the larynx are divided into two
groups: (1) the intrinsic and (2) the extrinsic muscles. The The thyroarytenoid (Fig. 7) is also a paired muscle which
intrinsic muscles alter the shape, tension, and position of appears to have evolved in function to allow the larynx to
the vocal folds within the larynx while the extrinsic mus­ produce precise changes in shape, position, and tensioning,
cles provide external support to the laryngeal framework for speech and singing as well as continuing with its
Chapter 2: Anatomy of the Larynx 17

Fig. 6: Lateral cricoarytenoid muscle. Fig. 7: Thyroarytenoid muscle.

original sphincteric action of protection of the lower transverse and oblique fibers. The transverse fibers run
airway. This muscle forms the main bulk in the vocal folds. between the posterior surfaces of each arytenoid and
It has two bellies, the internus and the externus. The internus, oblique fibers run from the apex of one arytenoid to the
referred to as the vocalis muscle, arises from the anterior posterior surface of the opposite side. When this muscle
commissure and inserts into the vocal process of the contracts it adducts the vocal folds by rotating both the
arytenoid. When it contracts the vocal folds are shortened arytenoids medially and causes closure of the posterior
and thickened. In isolation this action can lower the reso­ glottis and narrowing of the laryngeal inlet. The interar­
nating pitch of phonation. However, in life, there is a signi­ ytenoid muscle receives nerve supply from the recurrent
ficant overlay in the action of all individual muscles. The laryngeal nerve on both sides7 due to which we can detect
externus arises from the lower half of the thyroid cartilage movement of the ipsilateral arytenoid in unilateral vocal
and runs posteriorly to insert into the base of the arytenoid fold paralysis.
cartilage. This muscle also sends fibers which ascend
upward into the ventricular folds and are termed as the Posterior Cricoarytenoid
ventricularis muscle. There is no good evidence to show that
the internus and externus are indeed two separate muscles The posterior cricoarytenoid (Fig. 8) is the sole abductor of
however they are innervated by two different types of the vocal folds. Paralysis of the muscle on both sides can
nerve fibers. The external belly is supplied by the “fast- therefore lead to respiratory distress due to inability to
twitch” nerve fibers which are essential for coughing and open up the laryngeal inlet for breathing. This muscle
rapid protection of the airway. The vocalis on the other arises from the expanse of the posterior face of the cricoid
hand is innervated by the “slow-twitch” nerve fibers lamina and runs diagonally to insert into the posterior
which make the muscles contract in a sustained and very surface of the muscular process of the arytenoid. It has
accurate manner as is required for phonation. There are a horizontal belly which inserts into the medial aspect
some recent studies which suggest that the ventricularis of the muscular process, and a vertical belly which runs
fibers may be innervated by the superior laryngeal nerve in a straighter route and inserts into the lateral aspect
which may explain movement of the false vocal folds in of the muscular process. Due to the slightly different
cases of recurrent laryngeal nerve palsies.2 orientation of these fibers the contraction of the muscle
as a whole causes movement of the arytenoid along two
oblique axes. The horizontal belly is responsible for true
Interarytenoid abduction while the vertical belly plays more of a role in
The interarytenoid is an unpaired muscle (Fig. 8) which maintaining the arytenoid upright and regulating vocal
runs between the two arytenoids and consists of both fold length and tension.2
18 Section 1: History and Basic Sciences

Fig. 8: Interarytenoid muscle and posterior cricoarytenoid muscle. Fig. 9: Cricothyroid muscle.

Cricothyroid omohyoid, and thyrohyoid. All of these muscles act in

concert to provide stabilization to the laryngeal frame­
The cricothyroid muscle (Fig. 9) is a tensor of the vocal work. The suprahyoid muscles act in elevating the larynx
folds. It has two muscle bellies. The pars recta, the more while the infrahyoid group depress the larynx.
vertical component, arises medially from the superior
rim of the cricoid cartilage and inserts on the inferior
rim of the thyroid cartilage, while the pars obliqua, runs LIGAMENTS AND MEMBRANES
obliquely from the superior arch of the cricoid to insert on
the inferior cornu. Contraction of the cricothyroid muscle Thyrohyoid Membrane
bellies affects motion at the cricothyroid joint. When it The thyrohyoid membrane is a fibrous layer between the
contracts, it pulls the thyroid cartilage forward around the superior border of the thyroid cartilage and the body of
axis through the cricothyroid joint, increasing the distance the hyoid bone (Fig. 10). The membrane ascends some­
between the thyroid and arytenoid cartilages and stretching what behind the body of the hyoid and attaches on its
and tensing the vocal fold. This action is often referred to posterior surface. There is a mucosal bursa between the
as the “laryngeal tilt” or “rocking/pivoting the larynx”, and bone and this membrane. These features allow smooth
is important for singers while singing at high pitches. The movement over the membrane when the larynx ascends
downward tipping of the thyroid cartilage squeezes the in d­ eglutition. This membrane is thickened medially
cricothyroid space and therefore obliterates it. This action
and laterally to form what are known as the median and
of the cricothyroid also brings about some adduction of
lateral thyrohyoid ligaments. The membrane, toward its
the vocal folds and therefore this muscle is often grouped
more lateral portion, is pierced by the superior laryngeal
together with the adductors. Unlike all the other muscles
neurovascular bundle as it enters the larynx. The internal
of the larynx, which are innervated by the recurrent
branch of the superior laryngeal nerve can be anesthe­
laryngeal nerve, the cricothyroid muscle is the only
tized at its entry point into the thyrohyoid membrane,
muscle that is supplied by the external laryngeal branch of
by infiltrating local anesthetic agent just inferior to the
the superior laryngeal nerve.
greater cornu of the hyoid.8 The external component of a
combined laryngocele pushes out into the neck through
Extrinsic Muscles the thyrohyoid membrane and therefore is in close proxi­
These are the suprahyoid group and the infrahyoid group of mity with the superior laryngeal artery and the internal
muscles. The suprahyoid muscles are mylohyoid, digastric, laryngeal nerve.9 There are sometimes cartilaginous con­
geniohyoid, and stylohyoid. The infrahyoid group consists densations in the lateral thyrohyoid ligament. These are
of the strap muscles, viz. sternohyoid, sternothyroid, called cartilago triticea.
Chapter 2: Anatomy of the Larynx 19

Fig. 10: Thyrohyoid membrane and cricothyroid membrane. Fig. 11: Quadrangular membrane and conus elasticus.

Cricothyroid Membrane Conus Elasticus

This membrane connects the upper margin of the cri­ It is the thick fibroelastic support structure of the glottis
coid cartilage to the lower margin of the thyroid cartilage (Fig. 11). It is attached inferiorly to the superior border
(Fig. 10). The median condensation of fibers is called the of the cricoid cartilage and ascends upwards to attach to
cricothyroid ligament. This cricothyroid membrane can the anterior commissure anteriorly, and vocal process of
be punctured directly through the skin for emergency the arytenoid cartilage posteriorly. At this level, the conus
airway access, a procedure known as the cricothyrotomy.10 elasticus rolls medially to form the vocal ligament which
Many of the office-based laryngeal procedures [botox covers the vocalis muscle in the bulk of the true vocal folds.
injection for adductor spasmodic dysphonia/hyaluronic Anteriorly, the conus is con­tinuous with the cricothyroid
acid (HA) injection for medialization laryngoplasty, etc.] membrane and the median cricothyroid ligament.
are done by inserting the needle for injection through
the cricothyroid membrane. Another significance of this Vasculature
space is in the diagnosis of muscle tension dysphonia (MTD).
The larynx is supplied by the superior and inferior ­laryngeal
In patients with MTD the cricothyroid space, which can
arteries which are branches of the superior and inferior
normally be palpated in the neck, gets obliterated and may
thyroid arteries, respectively. The veins accompany their
be tender. This happens due to excessive tightness of the
fellow arteries. The superior laryngeal artery along with
muscles of the larynx.
the internal branch of the superior laryngeal nerve, pierce
the thyrohyoid membrane 1 cm anterior and superior to
Quadrangular Membrane the superior thyroid tubercle to enter the larynx (Fig. 12).
It is an accessory elastic support structure of the supra­ The cricothyroid artery is a branch of the superior laryngeal
glottic larynx (Fig. 11). It attaches to the lateral free edge artery which runs along the inferior border of the thyroid
of the epiglottis anteriorly and the arytenoids posteriorly. cartilage and supplies the cricothyroid muscle and the
The superior free edge of the quadrangular membrane cricothyroid joint. It then pierces the cricothyroid membrane
constitutes the aryepiglottic fold. As it continues inferiorly, to ascend up along the internal surface of the thyroid carti­
it forms the medial wall of the pyriform sinus. In its lage. While making a window in the thyroid cartilage dur­
further inferior extent, the membrane folds inwards ing thyroplasty, one might encounter bleeding from this
upon itself medially to form the vestibular ligament. The vessel. The inferior laryngeal artery enters between the fibers
mucosa covered vestibular ligament constitutes the bulk of the inferior constrictor muscle and anastomoses with the
of the false vocal folds. branches of the superior laryngeal artery of that side.
20 Section 1: History and Basic Sciences

Fig. 12: Blood supply and nerve supply of the larynx. Fig. 13: Laryngeal ventricle and saccule.


The larynx comprises potential spaces that become signi­ The true and the false vocal folds were earlier referred to
ficant in spread of malignancy. as vocal “cords”. As the understanding of the laryngeal
­structure improved, anatomists realized that rather than
Ventricle being a “cord” or a band being attached at either end and
suspended in the larynx, these are actually “folds” of mem­
The ventricle is the space between the false and true vocal
branes which are just lips of tissue covered with mucosa.
folds (Fig. 13). Each ventricle resembles a canoe laid on its
The false vocal folds or the vestibular folds are formed
side. It was historically known as the sinus of Morgagni.
by mucosa covering the vestibular ligament. They do not
Anteriorly the ventricular space ascends upwards into the
contain any muscle and are lined by respiratory epithelium.
false vocal folds, where it forms the saccule which contains
The false vocal folds may vibrate during phonation or
mixed mucinous glands. It is therefore termed the “oil
singing, especially during vibrato; but they do not have any
can” of the larynx secreting mucous which lubricates the
role in actual sound production. They assist in closing the
vocal folds. This area is not easily visualized by indirect
laryngoscopy. A malignancy in this region may therefore laryngeal inlet when the epiglottis tilts backward to seal
be missed. A tumor present in the ventricle can spread the glottis during swallowing.
easily to the paraglottic space and get upstaged. The true vocal folds are shelves of tissue over the thyro­
arytenoid muscle and as such have a four-layered complex
structure: the epithelium, Reinke’s space, vocal ligament,
Paraglottic Space
and vocalis muscle (Fig. 15).
It lies on either side of the glottis and is bounded laterally The epithelium over the anterior vibratory portion of
by the perichondrium of the thyroid cartilage and the the larynx is stratified squamous epithelium and in the
cricothyroid membrane and posteriorly by the mucous posterior glottis pseudostratified ciliated epithelium. The
membrane of the pyriform sinus. Anterosuperiorly it com­ epithelium is only about 5−25 cell thick, the most super­
municates with the preepiglottic space. It is therefore an ficial part containing only 1−3 cells which are lost due
important route for transglottic and extralaryngeal spread to the abrasions produced during phonation. The basal
of carcinoma of the larynx. Spread of malignancy into the lamina or the basement membrane zone (BMZ) provides
paraglottic region is a relative contraindication for laser support to the epithelium, and serves as a transition zone
excision.11 between the epithelium and the Reinke’s space. It has two
The preepiglottic space of Boyer (Fig. 14) has been layers: (1) the lamina lucida (low density, clear zone) and
described previously. (2) lamina densa (higher density of filaments). Anchoring
Chapter 2: Anatomy of the Larynx 21

Fig. 14: Pre-epiglottic space. Fig. 15: Layered microstructure of the vocal folds.

filaments, made of type IV collagen and fibronectin, ­fibers which joins the vocal folds to the inner perichon­
secure the lamina lucida to the lamina densa. Anchoring drium of the thyroid cartilage is called the Broyles’ tendon.
fibrils made of type VII collagen loop between the lamina The Broyles’ tendon contains both lymphatics and blood
densa and the underlying lamina propria. These anchoring vessels. It receives the attachments of the ligaments,
fibrils provide structural integrity to this delicate tissue membranes, and muscles from either sides of the larynx
transition interface, especially in the areas of maximum and thus serves as a natural barrier for malignancies of the
shear and stress and hence, their density is highest in glottis.14 Due to this, anterior spread of glottic malignancies
the mid-­membranous region which is the area prone to is usually supra- or infraglottic. Once the Broyles’ tendon
maximum phonotrauma.12 This mid-membranous region is breached, the malignancy erodes through to the thyroid
is also referred to as the “striking zone”. The number of cartilage.
anchoring fibrils is thought to be genetically determined, The macula flavae are located at the anterior and
which means that there might be a genetic predisposition posterior ends of the vocal folds. They have been likened
to developing vocal fold lesions. to shock absorbers linking the cartilage at either end of the
Beneath the basement membrane is the lamina propria vocal ligament to the vocal folds. These are elliptical
which has three layers: (1) superficial, (2) intermediate, and bodies, 1.5 mm × 1.5 mm × 1.0 mm in size, composed of
(3) deep. The superficial lamina propria (SLP), also known elastic fibers, collagen fibers, fibroblasts, and a ground
as Reinke’s space, is acellular and made up of loose fibro­ substance. The macula flava seem to control the synthesis
areolar tissue and extracellular matrix proteins, water, and of fibrous components in the vocal ligaments and are
loosely arranged fibers of elastin and collagen. The gelati­ responsible for the metabolism of the extracellular
nous nature of the SLP provides it with the viscoelasticity matrices which provides viscoelasticity to the lamina
that is needed during vibration and allows the overlying propria.15 They can therefore be regarded as the progenitors
epithelium (cover) to vibrate smoothly and at high speeds of the lamina propria. In feminizing laryngoplasty, the
over the underlying vocal ligament and muscle (body). anterior commissure is sacrified to make the vocal folds
This formed the anatomical basis of Hirano’s body-cover shorter, irreversibly damaging the macula flava and hence
theory.13 The intermediate layer (mostly composed of this surgery is considered as nonphysiological by many.
elastin fibers) and the deep layer (mostly composed of The posterior glottis or the interarytenoid region is
collagen fibers and fibroblasts) together form the vocal an ill-defined area at the junction of the posterior ends
ligament. Deep to the vocal ligament lies the vocalis of both vocal folds and postcricoid region. It constitutes
(thyroarytenoid) muscle which has already been described. 35−45% of the entire glottis length and 50−65% of the
The vocal folds on either sides join anteriorly at the entire glottis area.16 Consequently, most of the air passage
anterior commissure. The tendinous condensation of happens through this region of the glottis. Many authors
22 Section 1: History and Basic Sciences

believe that it is more intimately related to the subglottis PEARLS/KEY POINTS

rather than the glottis and should be regarded as a part ■■ The vocal folds lie closer to the inferior border of the thyroid
of it as such.17 The posterior glottis is a common site for cartilage and not at the midlevel.
stenosis, specially that caused by postintubation trauma. ■■ The posterior cricoarytenoid is the only abductor of the
The thickening of the interarytenoid region is seen quite vocal folds.
often in laryngopharyngeal reflux which is referred to as ■■ The intrinsic muscles of the larynx are all supplied by the
recurrent laryngeal nerve except the cricothyroid muscle,
interarytenoid pachydermia, drawing similarity with the which is supplied by the external branch of the superior
skin of an elephant (pachyderm). laryngeal nerve.
■■ No important structures lie between the skin and the crico­
Age- and Gender-Related Differences thyroid membrane and hence it can be directly punctured
through the skin to establish airway access in an emergency
in Vocal Fold Structure setting. This procedure is known as cricothyrotomy.
■■ Injection laryngoplasties can be done by entering the larynx
The infant vocal folds are 6−8 mm in length while the adult
through the cricothyroid membrane while the vocal folds are
vocal folds are around 16 mm. The infant lamina propria visualized by a flexible laryngoscope through the nose.
is only one cell thick and there is no vocal ligament. By ■■ Tenderness or obliteration of the cricothyroid space is a
age of 4 years the vocal ligament begins to appear. The sign of muscle tension dysphonia.
lamina propria becomes two layered by age 6−12 and by ■■ Ventricle of the larynx is one of the blind areas, which is
adolescence the layered microstructure is completely often difficult to visualize and hence a malignancy here
may be missed.
established. In females during puberty, the thyroarytenoid ■■ Spread of a malignancy to the paraglottic space is a relative
becomes thicker but remains narrow and supple. Under contraindication to laser excision of tumors.
the influence of progesterone, there is a diuretic effect ■■ The false vocal folds do not contain any muscle and have no
which decreases capillary permeability and traps extra­ role in sound production. However, they may vibrate dur­
cellular fluids out of the capillaries causing tissue ing phonation, particularly in vibrato singing.
■■ The gelatinous nature of the SLP gives it viscoelasticity
­congestion. This explains why some women experience
which allows the overlying epithelium (cover) to vibrate at
a subtle change in their voice quality during the menstrual high speed and yet smoothly, over the underlying vocal lig­
cycle. In men, the testosterone spurt during puberty ament and muscle (body).
causes the thyroid prominence to appear (Adam’s apple) ■■ The number of anchoring fibrils in the BMZ is thought to be
and the vocal folds to become longer and more rounded. genetically determined suggesting a genetic predisposition
toward developing vocal fold lesions.
Females have less HA in the Reinke’s space than males,
■■ The female Reinke’s space has less HA as compared to
which implies lesser protection from vibratory trauma and males, which leads to a higher tendency to develop vocal
overuse; and this may explain why women are more prone fold lesions.
to vocal lesions than men.12 ■■ In patients with laryngopharyngeal reflux, the interaryte­
As age advances, there is a steady increase in the elas­ noid region becomes thickened. This appearance is called
tin content of the lamina propria. The vocalis muscle atro­ “pachydermia”, likening it to the loose thick skin of an ele­
phant (pachyderm).
phies in both men and women, but in women, the SLP
becomes edematous and the epithelium thickens. In men
the deep layers of lamina propria show thickening due to REFERENCES
increased deposition of collagen.
1. Landry AM, Thompson DM. Laryngomalacia: disease pre­
sentation, spectrum, and management. Int J Pediatr. vol.
CONCLUSION 2012, Article ID 753526, 2012. doi:10.1155/2012/753526.
2. Jowett A, Shrestha R. Mucosa and taste buds of the human
A sound knowledge of anatomy helps us in understanding epiglottis. J Anatomy. 1998;193(Pt 4):617-8.
the physiology of phonation. Respecting the layered and 3. Dursun G, Keses R, Aktürk T, et al. The significance of
intricate microstructure of the vocal folds forms the basis pre-epiglottic space invasion in supraglottic laryngeal carci­
nomas. Eur Arch Otorhinolaryngol. 1997;254(Suppl 1):110-2.
of phonomicrosurgery. The framework surgeries are a 4. Johns MM, Klein A. Chapter 6: Type I thyroplasty. Laryngeal
direct result of a clear comprehension of the anatomy and Dissection and Phonosurgical Atlas. San Diego, CA: Plural
physiology of phonation. Publishing Inc; 2009. pp. 47-9.
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5. Rosen CA, Simpson BC. Chapter 1: Anatomy and physi­ 12. Colton R, Casper JK, Leonard R. Chapter 3: Morphology
ology of the larynx. Operative Techniques in Laryngology. of vocal fold mucosa: histology to genomics. In: Colton R,
Berlin Heidelberg: Springer; 2008. pp. 3-8. Casper JK, Leonard R (eds). Understanding Voice Problems:
6. Miller R. Pediatric anesthesia. Miller’s Anesthesia, 6th edition. A Physiological Perspective for Diagnosis and Treatment,
London: Churchill Livingston, Elsevier; 2005. pp. 2384-8. 4th edition. Philadelphia: Lippincott Williams & Wilkins;
7. Mu L, Sanders I, Wu BL, et al. The intramuscular inner­ 2011. pp. 64-75.
vation of the human interarytenoid muscle. Laryngoscope. 13. Hirano M. Morphological structure of the vocal cord as a vibra­
1994;(104) (1 Pt 1):33-9. tor and its variations. Folia Phoniatr (Basel). 1974;26(2):89-94.
8. Pani N, Kumar RS. Regional & topical anaesthesia of upper 14. Desloge RB, Zeitels SM. Endolaryngeal microsurgery at
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vations. Ann Otol Rhinol Laryngol. 2000;109:385-92.
9. Lancella A, Abbate G, Dosdegani R. Mixed laryngocele: a case
15. Sato K, Hirano M. Histological investigation of the macula
report and review of the literature. Acta Otorhinolaryngol
flava of the human vocal fold. Ann Otol Rhinol Laryngol.
Ital. 2007;27(5):255-7. 1995;104(2):138-43.
10. Bennett JD, Guha SC, Sankar AB. Cricothyrotomy: the ana­ 16. Hirano M, Kurita S, Kiyokawa K, et al. Posterior glottis:
tomical basis. J R Coll Surg Edinb. 1996;41(1):57-60. morphological study in excised human larynges. Ann Otol
11. Peretti G, Piazza C, Mora F, et al. Reasonable limits for Rhinol Laryngol. 1986;95(6 Pt 1):576-81.
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Otolaryngol Head Neck Surg. 2016; 24(2):135-9. (Suppl 2):1-24.

Physiology of Phonation

Sunita Chhapola Shukla, Nupur Kapoor Nerurkar

INTRODUCTION upward, lower the ribs or sternum to decrease the dimen -

sions of the thorax, or both thereby compressing the air in
A comprehensive understanding of the physiology of
the chest.
phonation includes understanding the histologic anatomy
Clinical Insight: Trauma or surgery that alters the structure
of the vocal folds along with the physiology of sound
or function of these muscles or ribs undermines the power
production. In this chapter, we have discussed various
aspects of the physiology of phonation with frequent clini- source of the voice, as do diseases that impair expiration
cal insights for better clinical correlation. such as asthma. Deficiencies in the support mechanism
The human larynx is vital for airway protection, res- often result in compensatory effects utilizing the laryngeal
piration, swallowing, and phonation. The aerodynamic muscles, which are not designed for power source func-
power generated by the chest, diaphragm, and abdominal tio s. Such behavior can result in decreased voice func-
musculature is converted into acoustic power by the vocal tion, rapid fatigue, pain and even structural pathology,
folds, which is heard as voice. 1 The powerhouse or gene- inc uding vocal fold nodules. 2 Treatment for such prob-
rator of our voice is the infraglottic vocal tract whic puts lems focuses on the correction of the underlying malfunc-
into vibration the true vocal folds creating a buzzing sound tion, often curing the problem and avoiding the need for
(phonation). This buzzing sound is amplified and given a laryngeal surgery.
signature character by the resonating system composed of
the supraglottic vocal tract. Finally, the "spoken word" is B. Phonating System
a result of the articulating system, composea of the lips,
The myoelastic-aerodynamic theory describes the com-
tongue, teeth, mandible and palate. Thus, speech is the
plex cycle that results in voice production. 3 At the begin -
end result of the phonating, resonating and articulating
ning of each phonatory cycle (Fig. 1), the vocal folds are
systems. Phonation, however, is the sound created solely
closed causing infraglottic air pressure to build-up. The
by the vibration of the vocal folds.
subglottic pressure rises and eventually pushes the vocal
folds progressively farther apart from the lower lip and air
A. lnfraglottic Vocal Tract begins to flow. Bernoulli's force created by the air passing
The infraglottic vocal tract serves as the power source for between the vocal folds combines with the mechanical
the voice and generates force that directs a controlled air- properties of the folds to begin closing the lower portion
stream between the vocal folds. Inspiratory muscles are of the glottis almost immediately, even when the upper
the diaphragm and the external intercostal muscles. The lip is still separating. The upper portion of the vocal folds
primary expiratory muscles are the abdominal muscles, have strong myoelastic properties that tend to make the
but internal intercostal and other chest and back mus- vocal folds snap back to the midline. This myoelastic force
cles are also involved. During quiet breathing, expiration becomes more dominant as the upper lip is stretched
is largely passive. Muscles of active expiration either raise and the subglottic force of the air diminishes because of
the intra-abdominal pressure; forcing the diaphragm the approximation of the lower lip. The upper lip then
Chapter 3: Physiology of Phonation 25

the closing phase is when the vocal folds are coming

together. The closed phase denotes the time at which the
membranous vocal folds are fully closed. The horizontal
transgression of mucosal wave is called amplitude and the
distance between the vocal folds is the glottal width. During
normal phonation, the mucosal wave travels in an infe­
rior to superior direction. The speed of the mucosal wave
ranges from 0.5 m to 1 m per second.4 The factors which
affect the speed and amplitude of the mucosal wave are
vocal fold length, airflow, subglottic pressure, and laryn­
geal muscle tone.5 A good pliability of the vocal folds
is essential for normal amplitude of the mucosal wave.
Periodicity of the glottal cycle is a regular repetition of
vibratory cycles such that each cycle has the same ampli­
tude and duration. Any deviation from this cycle is known
as aperiodicity.
Videostroboscopic vibratory parameters help the
clinician to assess the larynx. Fundamental frequency
describes the modal or basic frequency of an individual’s
phonation. In the evaluation of voice disorders, an indi­
vidual’s ability to optimize adjustments of air pressure and
glottal resistance is assessed. When high subglottic pres­
sure is combined with high adductory (closing) vocal fold
force, glottal airflow and the amplitude of the voice source
fundamental frequency are low. This is called pressed
phonation and can be measured clinically by a technique
known as flow glottography.6 If adductory forces are so
weak that the vocal folds do not make contact, the glottis
becomes inefficient at resisting air leakage, and the voice
source fundamental frequency is also low, causing breathy
phonation. Flow phonation is characterized by lower sub­
glottic pressure and lower adductory force. The amplitude
Fig. 1: Glottic mucosal wave. of the fundamental frequency can be increased by 15 dB or
more when the subject changes from pressed phonation to
returns to the m ­ idline completing the glottic cycle. Sub­ flow phonation.6
glottal pressure then builds up again and the cycle repeats
itself. This aeromechanical cycle is repeated over and over Pitch
and results in phonation. This traveling wave of mucosa Fundamental frequency (pitch) is defined as the number
from the inferior to superior surface of the vocal folds is of glottal vibratory cycles per second. The funda­mental
the mucosal wave. During phonation, the infraglottic frequency for an adult male during speech ranges
musculature makes rapid, complex adjustments because between 100 Hz and 150 Hz, for an adult female, between
the resistance changes almost continuously as the glottis 180 Hz and 250 Hz and between 205 Hz and 290 Hz for
closes, opens and changes shape. children.7 Laryngeal vibration results in the production
The vibratory cycle is divided into the open and of multiple frequencies at regular i­ntervals. Besides
closed phases. The open phase denotes the time at which the fundamental frequency, the other frequencies are
the vocal folds are at least partially open. This is further known as overtones. These frequencies are accentuated
divided into the opening phase which is the time when and ­diminished by the vocal tract. The resonators alter
the vocal folds are moving away from each other, whereas the shape and length of the vocal tract, which results
26 Section 1: History and Basic Sciences

Table 1: Factors contributing to the pitch.

Mass Tension Vocal fold length Subglottic pressure Pitch
Decrease Increase Decrease Increase Increase
Increase Decrease Increase Decrease Decrease

in change in the timbre of the voice giving the voice a vocal tract. Raising the air pressure creates greater ampli­
unique, recognizable sound.8 tude of vocal fold displacement from the midline and,
Changing either the air pressure or the mechani­ therefore, increases vocal intensity.
cal properties of the vocal folds can alter fundamental
frequency. When the cricothyroid muscle contracts, it Vocal Registers
makes the thyroid cartilage pivot and increases the dis­ Hollien suggested that registers should be defined in
tance between the thyroid and arytenoid cartilages, thus terms of laryngeal behavior, rather than in acoustic
stretching the vocal folds. This increases the surface area terms, as registers are governed by the degree of contrac­
of the vocal folds exposed to subglottal pressure and hence tion of the vocalis muscle.10 Hence, the terms loft, modal
makes the air pressure more effective in opening the glot­ and pulse registers can be used with less confusion. They
tis.9 In addition, stretching the elastic fibers of the vocal describe the vibratory pattern of the vocal folds and the
fold makes them more efficient at snapping back together. acoustic parameters produced.
The myoelastic aerodynamic mechanism of phonation
reveals that the vocal folds emit pulses of air, rather than
Loft Register (Falsetto)
vibrating like strings.
There are several important factors that contribute to The vocal folds are lengthened, extremely tense and thinned
the pitch including the mass of the vocal fold, the tension so that there is minimal vibration, creating a high-pitched
of the vocal fold, the length of the vocal fold and the level voice. The thin free edges are almost adducted, with incom­
of subglottic pressure (Table 1). plete glottal closure and high subglottic air pressure. Only
Clinical Insights: A heavier vocal fold will vibrate slowly the upper edge of the vocal fold vibrates. During the pro­
accounting for the lower pitched voice, i.e. smoker with duction of these high frequencies, the suprahyoid muscles
edematous vocal folds (Reinke’s edema) or a patient with raise the larynx and the pharynx is shortened.
masses on their vocal folds.
Type III thyroplasty, used to lower the pitch in puber­ Modal Register
phonics, works on the principle of decreasing tension and The vocal fold mucosa vibrates independently of the
increasing mass. The relaxation of the vocal fold is per­ underlying vocalis muscle with complete glottal closure
formed by retrusion (shortening the anterior posterior
and results in the mid-frequency range voice usually
length). An additional decrease in fundamental frequency
employed in speech and singing. They vibrate slowly along
may be obtained by combining this procedure with vocal
their whole length, the lower surfaces of their “lips” mak­
fold injection to increase vocal fold mass. The anterior web
ing contact and separating as the upper surfaces approxi­
creation surgery works on the principle of increasing pitch
mate in a rolling motion. In lowest notes, the infrahyoid
by decreasing length of the vibrating vocal fold.
muscles pull the larynx down.
Type IV thyroplasty (cricothyroid approximation),
used to raise the pitch in patients who have undergone a
male-to-female gender reassignment surgery, increases Pulse Register
the tension of the vocal folds by stretching them, thus (Glottal Fry, Vocal Fry or Creaky Voice)
raising vocal pitch. This terminology reflects the pulsatile nature of the laryn­
geal sound generated. The mucosal cover and underlying
Intensity muscle vibrate as a unit leading to a very low-frequency
Vocal intensity (loudness) depends on the degree to which phonation. It is characterized by a long closed phase com­
the glottal wave motion excites the air molecules in the pared to the open phase.
Chapter 3: Physiology of Phonation 27

C. Supraglottic Vocal Tract

(Resonating System)
This buzzing sound created by the vocal folds is amplified
and given a signature character by the resonating system
composed of the supraglottic vocal tract which includes
the pharynx, tongue, palate, oral cavity, nose and other
structures. It acts as a selective filter and resonator that
propagates a similar pattern irrespective of the funda­
mental frequency. Hence, in spite of a continuously varying
tone of voice, a constant quality or timbre is maintained.
Oral resonance is affected by the degree of jaw movement,
mouth opening, tongue raising and pharyngeal constric­
tion. Nasal resonance is affected by action of the velo­ Fig. 2: Histological anatomy of true vocal fold.
pharyngeal sphincter during speech or some degree of
nasal obstruction. The false vocal folds are located above
the true vocal folds and do not make contact during epithelium only. The covering of the free edge of the vocal
normal speaking. They are considered to be used for fold is adapted for phonatory vibration. The stratified
forceful laryngeal closure and are a component of the squamous epithelium layer of the mucosa is very thin with
resonance chamber.2 no mucous glands and thus helps to maintain the shape of
the vocal folds. The surface cells slough off into the laryn­
D. Histologic Anatomy of the Vocal Fold geal lumen as new cells migrate superiorly and medially
to replace them. The luminal layer of the mucous blanket
The human vocal folds have a unique microanatomy. An
is composed of mucin molecules, and ensures adequate
understanding of vocal fold histology and cellular physio­
moisture and lubrication of the vocal folds. The inner
logy helps to understand, diagnose, and treat pathology
serous layer has high water content and is in direct con­
of the vocal folds. The Cover-Body theory of vocal fold
tact with the squamous cells of the vocal fold epithelium
motion was proposed by Hirano in 1974 and describes the
and the cilia of the pseudocolumnar cells of the glottis.
mucosal wave of the vocal folds.11 Histologically, the vocal
This facilitates the mucociliary transport of secretions up
folds consists of five layers (Fig. 2): squamous epithelium,
from the trachea and through the glottis for expectoration.
lamina propria (three layers) and the vocalis muscle.
Inhibition of mucociliary clearance can lead to impaired
These five anatomical layers work as increasingly stiffer function of the upper respiratory tract.
three mechanical layers during vibration. The “cover” is
composed of the epithelium and the superficial layer of Clinical Insight: In vocal fold lesions, e.g. nodules or polyps,
the lamina propria. The intermediate and deep layers of the area of insult is limited to the epithelium and superfi­
the lamina propria comprise the “transition” layer and the cial layers of the lamina propria. The healing process in
vocalis muscle act as the “body”. As air passes between the these two areas results in a minimal effect on vocal fold
vocal folds, the loose “cover” moves in a wave-like motion function because the fibers of the lamina propria are
over the stiffer “body”. The cover is pliable and elastic, ­generally restored in an orientation parallel to the epithe­
while the body uses its contractile properties to allow for lium. If the injury or surgery involves both the epithelium
the adjustment of the stiffness of the vocal fold. and the deep layer of the lamina propria, then the scar
can develop perpendicular to the epithelium, resulting in
Epithelium stiffness of the vocal fold leading to reduction of the vocal
wave and permanent changes in voice.12
The epithelium of the larynx is squamous, ciliated colum­
nar, or transitional. The upper half of the laryngeal surface
of the epiglottis, the upper part of the aryepiglottic folds,
Lamina Propria
and the posterior commissure are covered with squamous Lamina propria consists of three layers: superficial, inter­
epithelium. The vocal folds are covered with squamous mediate and deep. The superficial layer of the lamina
28 Section 1: History and Basic Sciences

propria (SLLP), or Reinke’s space, is a potential space com­

posed of loose, fibrous tissue in an extracellular matrix
(ECM). It is extremely pliable and offers little resistance
to vibration. The ECM is the key component of the SLLP
that allows this motion. The interstitial proteins also give
the vocal fold the ability to absorb the shock of repeated
impact from phonation. Majority of benign vocal fold
lesions occur in this layer, i.e. vocal fold polyps, nodules,
cysts and polypoid corditis (Reinke’s edema).13
Clinical Insight: Reinke’s edema mostly occurs due to
heavy cigarette smoking and occasionally in severe hypo­ Fig. 3: Basement membrane zone.
thyroidism. The entire membranous vocal fold from the
vocal process to the anterior commissure is edematous.
The edema occurs as a response to the chronic irritation primarily cellular epidermis to adhere to the amorphous
of the cigarette smoke or as a manifestation of myxedema and gelatinous lamina propria. Excessive disruption of
in hypothyroidism. The fundamental frequency during this anchoring system leads to change in voice production.
phonation is decreased due to the increased mass of the The number of anchoring fibers per unit area appears
affected vocal fold. The treatment is to remove the chronic to be genetically determined.15 A person with fewer
irritant, in case of smoking, or to correct the hormone anchoring fibers might be predisposed to the develop­
deficiency, as in hypothyroidism. If a patient continues to ment of vocal fold nodules.14
have significant dysphonia despite these measures, surgi­
Clinical Insight: The BMZ helps to differentiate between
cal treatment is advised.
carcinoma in situ (CIS) and invasive carcinoma of the
The intermediate layer of the lamina propria also
vocal folds. CIS of the vocal fold is defined as the pres­
consists of elastic and collagenous fibers but at a higher
ence of atypical cells within the epithelial layer of the vocal
concentration than the superficial layer. The deep layer is
fold without evidence of invasion through the BMZ. Once
dense, fibrous and has a high concentration of collagen
cancerous cells infiltrate the BMZ, the process becomes
bundles. Some collagenous fibers of the deep layer of the
invasive and the risk of regional and distant metastases
lamina propria insert into the muscle fibers of the vocalis
increases. Therefore, great care must be taken to dissect
muscle, and hence are not easily separated. The vocalis
below the BMZ when performing a biopsy of a suspicious
(medial part of the thyroarytenoid) muscle provides the
vocal lesion to ensure that the correct diagnosis is made.
main mass of the vocal fold and the muscle fibers run
Human vocal folds are subjected to continuous
para­ llel to the free edge of the vocal fold. The vocal
mechanical trauma resulting from the constant stress
ligament is a key landmark for the depth of dissec­
of phonation. Chronic phonotrauma occurs in the set­
tion of a benign laryngeal lesion in laryngeal microflap
ting of repeated episodes of acute phonotrauma that
surgery. Once the epithelium has been incised and the
SLLP bluntly elevated, the vocal ligament appears laterally result in long-standing vocal fold damage. This damage
as a shiny, yellow-white strip of elastic tissue. could present in the form of vocal fold scarring as seen
in benign vocal fold lesions such as nodules. These occur
with repeated injury of the basement membrane. Kotby
Basement Membrane Zone et al. report intercellular junction gaps, disruption of the
The vocal fold epidermis is secured to the superficial basement membrane, and focal collagen deposition in
lamina propria through the basement membrane zone nodules.16 Fibronectin, an adhesion molecule, located in
(BMZ).14 The BMZ is a collection of protein and nonpro­ the basement membrane, is also thought to be increased
tein structures that help the basal cells of the epidermis in nodules. It is also believed that the disruption of the
secure themselves to the lamina propria. The basal cells basement membrane places the nodule at an increased
have anchoring filaments and fibers that attach them­ risk for repeated injury, leading to propagation of scar over
selves to laminar proteins in the lamina propria (Fig. 3). time. Polyps occur due to repeated acute vascular trauma
This delicate and flexible anchoring system allows the instead of disruption of the basement membrane and
Chapter 3: Physiology of Phonation 29

have less deposition of fibronectin. While nodules appear of the lamina propria. Their location suggests that these
to be the end result of wound healing with the deposition cells are present to combat inflammatory agents crossing
of fibronectin as early scar, polyps may be an arrest of the the epithelial layer. Fibroblasts are present in all layers of
wound-healing process following the inflammatory phase.17 the vocal fold and replace damaged proteins of the l­amina
propria. Myofibroblasts are fibroblasts that are cells of
Histological Variations repair.20 They are found in a higher density in the superfi­
cial layer of the lamina propria and are capable of repair­
The vocal fold, histologically, is fairly consistent along its ing minor injuries efficiently, without compromising vocal
length except at two places. The collagenous fibers at the fold tissue or function. Hence, the voice must be rested for
anterior most portion of the vocal fold are attached to 2–3 days to allow the myofibroblasts to perform needed
the inner thyroid perichondrium. This forms the anterior repairs.
commissure tendon (Broyle’s tendon). The intermediate The noncellular ECM contains proteins (fibrous and
layer of the lamina propria is thickened at the anterior and
interstitial), carbohydrates and lipids. The two most
posterior ends of membranous vocal folds forming the
important fibrous proteins are collagen and elastin. Col­
anterior and posterior macula flava. The anterior macula
lagen provides strength and structure to the vocal fold,
flava serves as a transition zone between the stiff thyroid
while elastin allows the vocal fold to maintain its original
cartilage and the pliable membranous vocal fold, while the
shape. Interstitial proteins (proteoglycans) affect tissue
posterior macula flava serves as a transition between the
viscosity and have shock absorbing property. They include
membranous vocal fold and the stiff vocal process of the
hyaluronic acid, decorin, fibromodulin, versican, heparin
arytenoid cartilage. They cushion the vocal folds and pro­
sulfate proteoglycan, and aggregan biglycan.21 Hyaluronic
vide protection from mechanical damage caused by vibra­
acid is a glycosaminoglycan polymer of disaccharides
tion.18 The maculae flavae are elliptical in shape and are
composed of repeating units of glucuronic acid and
composed of fibroblasts, elastic fibers, collagenous fibers,
acetylglucosamine.22 It readily binds with water to form
and ground substance. Fibroblasts in the maculae flavae
a gel-like substance that affects the viscoelasticity of the
synthesize, and occasionally engulf, the elastic and colla­
lamina propria, determining tissue viscosity, osmosis, and
genous fibers.
flow resistance.23 The ECM is regulated by fibroblasts and
A newborn’s vocal fold has loose, pliable and thick
lamina propria with no evidence of vocal ligament. Ante­ is influenced by age and gender. Older or damaged pro­
rior and posterior ends of membranous vocal fold have teins in this matrix are constantly replaced by fibroblasts.
some fibrous tissue and immature macula flava. An Decrease in the collagen turnover with age and cross-link­
immature vocal ligament emerges between the age of ing of older proteins results in less elastic and stiffer colla­
1 year to 4 years. Differentiation between the two layers gen leading to less elastic and stiffer vocal fold.14
of vocal ligament starts between 6 years and 12 years of
age and the liga­ment becomes thicker. After adolescence, E. Neural Control
the three-layered lamina propria becomes evident. With The physiology of voice production is extremely complex.
increasing age the epithelium does not change much, but The command for vocalization involves complex interac­
the superficial layer of lamina propria becomes edema­ tion among brain centers for speech and other areas. The
tous and thicker. Elastic fibers in the intermediate layer “idea” of the planned vocalization is conveyed to the pre­
become loose, atrophied and thinner. The collagenous central gyrus in the motor cortex, which transmits instruc­
fibers of the deep layer becomes thicker and denser and tions to the motor nuclei in the brainstem and spinal
the vocalis muscle tends to atrophy.19 cord. Messages are sent out for coordinated activity of the
larynx, the chest and abdominal musculature and the
Lamina Propria Components vocal tract articulators. Additional refinement of motor
The lamina propria of the vocal fold consists of cellular activity is provided by the extrapyramidal and autonomic
and noncellular (extracellular) components.14 The cellu­ nervous systems. These impulses produce sound, which
lar lamina propria contains fibroblasts, microblasts, and also acts as auditory feedback and is transmitted from
macrophages. Macrophages are found in higher concen­ the ear through the brainstem to the cerebral cortex, and
trations just below the BMZ and in the superficial layer adjustments are made to fine-tune the sound produced.
30 Section 1: History and Basic Sciences

CONCLUSION 8. Sunberg J. Vocal tract resonance. In: Sataloff RT (ed).

Professional Voice: The Science and Art of Clinical Care. San
The vocal folds are put into vibration by the pulmonic air Diego, CA: Singular Publishing Group, Inc.; 1997. 167-84.
stream and the sound produced is a complex tone con­ 9. Sataloff RT. Clinical anatomy and physiology of the voice.
In: Sataloff RT. Professional Voice: The Science and Art of
taining a fundamental frequency and many overtones.
Clinical Care, 3rd edition. San Diego, CA: Plural Publishing,
The pharynx, oral cavity and nasal cavity act as a series of Inc.; 2005. pp. 143-78.
interconnected resonators. This gives a specific charac­ 10. Hollien H. On vocal registers. J Phonetics. 1974;2:125-43.
teristic to a person’s voice. It is essential for a surgeon to 11. Hirano M. Morphological structure of the vocal cord
understand the physiology of phonation and to evaluate as a vibrator and its variations. Folia Phoniatr (Basel).
the phonating, resonating and articulating system along
12. Benninger MS, Jacobson B. Vocal nodules, microwebs, and
with the power source, for correct diagnosis and treatment surgery. J Voice. 1995;9(3):326-31.
of dysphonia, especially for professional voice users. An 13. Gray SD, Hammond E, Hanson DF. Benign pathologic
interdisciplinary team of laryngologist, speech therapist responses of the larynx. Ann Otol Rhinol Laryngol. 1995;
and occasionally neurologist and gastroentero­logist helps 104(1):13-8.
14. Gray SD. Cellular physiology of the vocal folds. Otolaryngol
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Physiology of Swallowing

Bhagyashree Bokare, Shraddha Singh

Swallowing is a process by which a bolus of liquid or food
is transported from the oral cavity to the stomach while
protecting the airway.
One of the most primitive functions associated with
survival, yet least appreciated ones, it is an elaborate
execution of flawlessly coordinated rapid neuromuscular
tasks across multiple systems, still not understood com­
pletely. We swallow an average of over 1000 times in the
day, effortlessly.1
Fig. 1: Larynx—Aquatic mammal.
Eating is an obligatory act of sustenance beginning
with a desire to eat. Inability to swallow can be devas­
tating. It causes dehydration and nutritional deficiency EVOLUTION
leading to poor health. Infrequent or inefficient swallow­
ing leads to drooling or aspiration related problems. Its Unique to human evolution is the development of the
psycho­logical impact can be severe. Eating and eating aerodigestive tract.
together is enjoyable, gratifying and its deprivation leads What sets us apart is our distinctive mode of vocaliza­
to isolation, even depression. The financial cost of treat­ tion made possible by the descent of larynx in evolution,
ing dysphagic patients largely underestimated. The true aptly described as nature’s great experiment. As life moved
from water to land, larynx acquired new functions apart
incidence of dysphagia is unknown since it coexists with
from sphincteric protection of the airway. Effective valving
several com­orbid conditions especially those related to
for raising of intrathoracic pressure in climbing, bearing
aging. With increasing geriatric patients and advanced
down, etc. and production of sound.3
critical care globally, it is likely to assume epidemiologic
In aquatic mammals, the larynx is primarily intra­
narial C1 allowing simultaneous breathing while gulping
Dealing with dysphagic patient is an integral part of
food. Sound production for echo navigation is minimal
everyday clinical practice, more so, for our subspecialty (Fig. 1). Terrestrial species have slightly lowered larynx
where we deal with the structures directly related to swal­ (C1-3) but expanded structures that allow epiglottis to
lowing. An intimate knowledge of the normal function palate contact, with a mammalian template of two tube
with respect to, anatomy of structures involved and their configuration for separate airway and food passages. This
particularly complex neurophysiology is fundamental for allows for sucking, swallowing, ruminating, prey trans­
insight into dysfunction in dysphagia and appropriate portation with jaws while breathing, and detecting scent
intervention. of prey or predators simultaneously. Limited modification
This chapter aims at a discussion to facilitate such of sound is achieved by the oral cavity, lips and jaws. In
understanding. primates, the larynx descended further (C2-C3), allowing
32 Section 1: History and Basic Sciences

Fig. 2: Larynx—Terrestrial mammals.

Fig. 3: Larynx—Hominid versus man.

breaking of contact between epiglottis and soft palate dur­

ing vocalization and swallowing of large boluses due to
extensive mobility. However because of the small pharynx,
sounds were still severely limited4 (Fig. 2).
Fossil studies of hominids continue to show the two-tube
configuration with a descended hyoid in Neanderthals. With
emergence of Homo Sapiens the basicranium changed, the
larynx disengaged from skull base with uncoupling of the air
and food conduits, suggesting swallowing, breathing vocaliz­
ing patterns similar to modern man3 (Fig. 3).
This allowed for enhanced tidal oral respiration and an
enlarged supraglottic pharynx, permitting the formation
of vowels sounds [i] [a] and [u] inherent to human
languages, endowing a range vocalization nonexistent in
our ancestors or any other species!5 Fig. 4: Pharynx-intersection of the air and the food passages.
As passages for air and food intersected the risk of
aspiration or reflux became dire and permanent. Protec­
tion of the airway now became a vital part of swallowing
with mechanisms for precise neuromuscular coordination
and reflexes, turning swallowing into the complex, highly Swallowing involves the transport of bolus along passages
evolved function that it is (Fig. 4). within the oral cavity, pharynx and esophagus by a series
Chapter 4: Physiology of Swallowing 33

Fig. 5: Bony framework of head and neck.

of rapidly coordinated neuromuscular actions, while

protecting the airway.
Several structures interact with one another for a suc­
cessful swallow.
Bones of the base skull, maxilla and mandible, hard
palate, the styloid, mastoid, hyoid, cervical vertebrae all
either support structures or anchor muscles and that aid
in swallowing. Movement of the hyoid is central to and is
considered a direct indicator of normal swallowing6 (Fig. 5).
The larynx and its cartilages thyroid, cricoid, arytenoid
and epiglottis (Fig. 6) actively or passively participate in
swallowing by sphincteric closure7 and elevation of intrin­
sic and extrinsic muscles (protection of the airway, dilata­
tion of the pharynx and opening of the upper esophageal
sphincter)8 (Figs. 7A and B).
In adults, sixteen pairs of teeth help in cutting, grind­
ing and chewing food in the oral preparatory phase.9
Three pairs of major along with numerous minor Fig. 6: Cartilages of larynx.
salivary glands produce saliva that is critical to mastica­
tion, facilitates taste and smell, assists in transport of bolus
and maintains oral hygiene and contains enzymes for tongue, salivary gland openings and is continuous with
digestion10 (Fig. 8). the pharynx11 (Fig. 9).
The oral cavity is where bolus is first received and pre­ Soft palate is a soft fibromuscular flap consisting of five
pared for swallowing. The oral cavity, bounded by the lips, pairs of muscles in a sling separating oral cavity from the
cheeks, hard palate and floor mouth contains the teeth, nasopharynx.11 It helps in directing or containing the bolus
34 Section 1: History and Basic Sciences

by tensing and its sphincteric contraction provides oropa­ tenting during bolus manipulation and transport. They
latal or palatopharyngeal seal12 (Figs. 10A and B). also help in opening the jaw. Muscles of mastication (Fig.
The tongue is a highly specialized organ involved in 13) along with muscles of floor mouth, tongue and soft
swallowing, taste and speech. It has a mobile oral and a palate, work synchronously and rhythmically in prepara­
fixed pharyngeal part. Its papillae, vallate, fungiform con­ tion of the bolus and its transport.12
tain taste buds and filliform papillae provide masticatory Pharynx is a muscular tube, 12 cm long, from the base
help by providing friction.10,11 Muscles of the tongue, four skull to the cricoid, through which the food and air pas­
sages intersect and pass (Figs. 14A and B). Its walls consist
extrinsic and four intrinsic, impart it an amazing flexibility
of mucosa, pharyngobasilar fascia, muscular layer, and
to manipulate food, suck, swallow, push by changing its
bucopharyngeal fascia. The pharyngeal plexus of nerves
shape and position13 (Figs. 11A and B).
lies outside the muscular layer. It is posteriorly related to
The floor mouth mucosa covers the sheet of muscles cervical vertebrae and deficient anteriorly where it opens
attaching to the inner side of the mandible. (Suprahy­ into the nose, oral cavity and larynx, dividing it into the
oid muscles) (Fig. 12). They provide counter pressure by nasopharynx, oropharynx and hypopharynx11 (Fig. 15).

Fig. 7A: Larynx—Intrinsic muscles.
Chapter 4: Physiology of Swallowing 35

Fig. 7B: Larynx—Extrinsic muscles.

Fig. 8: Teeth and salivary glands.

36 Section 1: History and Basic Sciences

The oropharynx contains the free surface of the epi­ and coming together in sphincteric action during swal­
glottis, valleculae, base of the tongue and palatine arches lowing.7 The epiglottis during deglutition protects the
with the tonsil. Whereas the laryngeal inlet with aryepi­ laryngeal inlet by folding over it and diverging the bolus
glottic folds, pyriform fossae, and post-cricoid area form (Fig. 17). Its surface also contains number of sensory
the hypopharynx (Fig. 16). Mucosal folds between the receptors important for initiating the swallow and laryn­
base tongue and epiglottis form the valecullae. The pyri­ geal protective reflexes.14
form fossae are two blind sacs formed by folds of mucosa The Esophagus is a 18–26 cm long muscular tube from
draping the aryepiglottic folds and thyroid laminae that the hypopharynx to the stomach, normally collapsed at
connect into the post-cricoid region.11 Boluses may rest. It has 4 layers consisting of the mucosa, submucosa,
accumulate there before the swallow is triggered or may muscle and adventitia. The muscle layer is composed
penetrate the laryngeal vestibule before being expecto­ of inner circular and outer longitudinal fibers (Figs. 18A
rated or aspirated.12,14 and B). The upper esophagus, including the upper eso­
The aryepiglottic folds actually protect the airway by phageal sphincter (UES), is composed of striated muscle,
rising up as ramparts on either sides of the laryngeal inlet the middle esophagus contains a mixture of both smooth
and striated muscle, the distal third of the esophagus and
the lower esophageal sphincter (LES) exclusively contain
smooth muscle. The Meissner’s autonomic plexus under
the submucosa is responsible for afferent sensation and
the myenteric Auerbach’s plexus that lies between the two
layers of muscles, for peristalsis. The circular fibers con­
tribute to the UES and LES, that prevent reflux of gastric
contents into the pharynx and entry of air into the stomach
at rest by tonic constriction.15
Upper esophageal sphincter: Manometric and fluoro­
scopic studies indicate a 2–4 cm region of raised
intraluminal pressure at the level of the cricoid. This
pharyngoesophageal segment extends slightly beyond
the area of the cricopharyngeus, suggesting that the
lowermost fibers of the thyropharyngeus as well as the
uppermost fibers of the circular esophageal muscle may
Fig. 9: Oral cavity. contribute to part of this UES16 (Fig. 19).

Figs. 10A and B: Soft palate.
Chapter 4: Physiology of Swallowing 37

Figs. 11A and B: (A) Tongue—parts; (B) Tongue—Extrinsic and intrinsic muscles.

Fig. 12: Floor of mouth muscles.

38 Section 1: History and Basic Sciences

The cricopharyngeus is an unpaired C-shaped muscle, within the diaphragmatic hiatus with raised resting pressure
attached anteriorly to the cricoid. It has a high proportion approximately 10–30 mm Hg more than intragastric pres­
of slow-twitch, highly oxidative fibers with high elastic sure, mediated by autonomic neural mechanisms15 (Fig. 20).
tissue content, with special capability of sustained acti­vity.
At rest, tonic vagal stimulation plus passive forces from Muscles
elasticity of the walls keep the UES closed. Mean pressure Swallowing involves approximately 30–35 muscles. These
here between 30 amd 85 mm Hg is asymmetrically distri­ muscles are divided into groups depending on the organ,
buted (more in antero-posterior axis).16 region involved or task accomplished and are described in
Lower esophageal spincter is a discrete area of 2–4 cm Table 1. Muscles of the pharynx and cervical esophagus
thickened zone of asymmetrically circular smooth muscle are all striated, those of the lower end of esophagus are
tonically contracted as a function of the muscle itself, smooth and in the thoracic esophagus mixed.17

Fig. 13: Muscles of mastication.

Fig. 14A
Chapter 4: Physiology of Swallowing 39

Figs. 14A and B: Muscles of pharynx.

Fig. 15: Pharynx division.

40 Section 1: History and Basic Sciences

These muscles are either obligate or facultative in

deglutition. Their action during swallowing comprises an
extraordinary sequence of excitation or inhibition in pairs,
that may be sequential or synchronized, sustained or
ballistic like or even pacemaker like or rhythymic.18
Familiarity with the specific action of these muscles,
along with the nerve supply and their interaction with each
other is crucial to diagnosing where exactly dysfunction is
occurring and thus, what strategies may be remedial.

Neural Control
For swallowing, both supramedullary and medullary
neural circuits along with concerned cranial nerves are all
Fig. 16: Laryngeal structures as seen on laryngoscopy. crucial links.

Fig. 17: Epiglottis folding over the laryngeal inlet.

Figs. 18A and B: Esophagus.
Chapter 4: Physiology of Swallowing 41

Fig. 19: Upper esophageal sphincter. Fig. 20: Lower esophageal sphincter.

Table 1: Major muscles related to swallowing with their actions and innervation.
Muscles Action Cranial nerves
Tongue muscles (Intrinsic)
Superior longitudinal Shortens tongue, raises tip and lateral margin of tongue Hypoglossal nerve (XII)
Inferior longitudinal Shortens tongue, pulls tongue tip down Hypoglossal nerve (XII)
Transverse Narrows and elongates tongue Hypoglossal nerve (XII)
Verticalis Flattens and widens tongue Hypoglossal nerve (XII)
Tongue muscles (Extrinsic)
Genioglossus Protrusion of tongue , depresses center of tongue Hypoglossal nerve (XII)
Hyoglossus Depresses and retrudes tongue Hypoglossal nerve (XII)
Styloglossus Elevates and retracts tongue Hypoglossal nerve (XII)
Palatoglossus Depresses soft palate, moves palatoglossal fold towards midline, Pharyngeal plexus (IX, X)
elevates back of tongue
Palatal muscles
Levator veli palatini ■■ Elevates the soft palate above neutral position Pharyngeal plexus (IX, X)
Tensor veli palatini ■■ Tenses the soft palate Trigeminal nerve (V)
■■ Opens pharyngotympanic tube for pressure equalization
Palatoglossus ■■ Depresses the palate Pharyngeal plexus (IX, X)
■■ Moves palatoglossal arch toward midline
■■ Elevates back of the tongue
Palatopharyngeus ■■ Depresses the soft palate Pharyngeal plexus (IX, X)
■■ Moves palatopharyngeal arch toward midline
■■ Elevates the pharynx
Uvulae ■■ Elevates and retracts the uvula Pharyngeal plexus (IX, X)
■■ Thickens the central region of soft palate
Masticatory muscles
Muscles opening jaw
Lateral pterygoid Moves mandible laterally (rotary chew), depresses and protrudes Trigeminal nerve (V)

42 Section 1: History and Basic Sciences

Muscles Action Cranial nerves
Anterior belly, digastric Elevates the hyoid Trigeminal nerve (V)
Posterior belly, digastric Raises the hyoid bone Facial nerve (VII)
Mylohyoid Elevates hyoid, lowers mandible Trigeminal nerve (V)
Geniohyoid Elevates hyoid, lowers mandible C1(ansa cervicalis) and XII
Muscles closing jaw
Temporalis ■■ Elevation and retraction of mandible Trigeminal nerve (V)
■■ Side to side movements of the mandible
Masseter Elevation of the mandible Trigeminal nerve (V)
Medial pterygoid ■■ Elevation and side to side movement of mandible Trigeminal nerve (V)
■■ Assists lateral pterygoid in mandibular protrusion
Pharyngeal muscles
Superior pharyngeal Constricts pharynx Vagus nerve (X)
Middle pharyngeal Constricts pharynx Vagus nerve (X)
Inferior pharyngeal Constricts pharynx Vagus nerve (X)
Stylopharyngeus Elevates pharynx Glossopharyngeal nerve (IX)
Salpingopharyngeus Elevates pharynx Vagus nerve (X)
Palatopharyngeus ■■ Depresses the soft palate Pharyngeal plexus (IX, X)
■■ Moves palatopharyngeal arch toward midline
■■ Elevates the pharynx
Laryngeal muscles
Larynx (intrinsic)
Lateral cricoarytenoid Adduct the vocal cords and closes the rima glottidis Recurrent laryngeal nerve (X)
Posterior cricoarytenoid Abducts the vocal cords Recurrent laryngeal nerve (X)
Interarytenoid Adducts the vocal folds by approximating the arytenoid cartilages Recurrent laryngeal nerve (X)
thereby closes the glottis opening
Larynx (extrinsic)
(Suprahyoid muscles)
Mylohyoid Elevates hyoid, tenses floor of mouth Trigeminal nerve (V)
Anterior belly, digastric Fixed mandible, elevates hyoid; fixed hyoid, depresses mandible Trigeminal nerve (V)
Posterior belly, digastric Elevates and retracts the hyoid Facial nerve (V)
Stylohyoid Elevates hyoid Facial nerve (V)
Hyoglossus Depresses and retracts tongue Hypoglossal nerve (XII)
Geniohyoid Fixed mandible, pulls hyoid forward; fixed hyoid, depresses and C1 (ansa cervicalis) and XII
retracts mandible
(extrinsic) (infrahyoid
Sternohyoid C1–C3
Sternothyroid Depresses the hyoid bone and larynx during swallowing and C1–C3
Omohyoid C1–C3
Thyrohyoid C1 (ansa cervicalis) and XII
Chapter 4: Physiology of Swallowing 43

The cranial nerves V, VII, IX, X, XII are emissaries of i. DSG (dorsal swallowing group), situated near the
information to and commands from the higher centers nucleus tractus solitarius, that generates the swallow­
to the peripheral end organs for execution of the swallow, ing pattern and
carrying sensory motor, special sensory and secretomotor ii. VSG (ventral swallowing group), situated adjacent to
or autonomic impulses19 (Figs. 21A and B). Not all nerves Nucleus ambiguous, that distributes the swallowing
carry all types of fibers. Their description, functions with drive to various motor neurons.
supplied end organs and muscles are described in Table 2. Complete anatomical structural integrity and an intact
Both voluntary and automatic swallowing show acti­ nerve supply are mandatory for a normal swallow.
vation of a number of spatially and functionally distinct
loci within the cortex and midbrain. Several cortical and PHYSIOLOGY OF SWALLOWING
subcortical structures are identified which play an impor­ The normal swallow has been traditionally described in
tant role in swallowing19,20 (Figs. 22A and B) (Table 3). 3 stages consisting of an oral stage (further subdivided
Connections are sent via dorsal and ventral cortico­ oral preparatory stages), oral propulsive, pharyngeal and
bulbar tracts to the brainstem centers in medulla for esophageal stage.
swallow programming. Currently two models are accepted to describe the
Cranial nerve (CN) nuclei that receive general afferent physiology of swallowing.12
and special sensory information are NTS (Nucleus tractus 1. Staged/Sequential model for drinking liquids.1
solitarius), STN (Spinal tract nucleus) and, Mesencephalic 2. Process model for eating solid food with considerable
and chief sensory nuclei of trigeminal. CN nuclei involved overlap and integration between oral preparatory and
in efferent pathways are the motor nuclei of Vagus, the propulsive phases of swallow.21
nucleus ambiguous (NA), Hypoglossal nucleus, the motor Although we think of the events happening one after
nuclei of Trigeminal and Facial, Cervical spinal roots the other, they are often synchronous with interaction
(C1 and C3) and Superior and Inferior salivary nuclei and between voluntary and involuntary aspects merged and
Dorsal motor nucleus of Vagus (DVN) for secretomotor unclear.8,14
and autonomic control18 (Fig. 23).
The CPG (central pattern generator), that regulates the
Oral Preparatory Phase
swallow, is formed by two main group of interneurons also This consists of bolus reception, containment and masti­
known as lateral and medial swallowing centers and their cation till bolus delivery into the pharynx. Indispensable,
connections located in the medulla18 (Fig. 24). when food is not swallowed as whole, the sight, smell of

Fig. 21A
44 Section 1: History and Basic Sciences

Fig. 21B: Cranial nerves in swallowing. (Red: Afferent; Blue: Efferent).
Table 2: Cranial nerves involved in swallowing.
Trigeminal Three sensory Motor branches: Three branches:
(V) nuclei ■■ Masseter ■■ V1 ophthalmic
■■ Mesencephalic ■■ Temporalis ■■ V2 maxillary
■■ Chief sensory ■■ Medial pterygoid ■■ V3 mandibular
■■ Spinal nucleus ■■ Lateral pterygoid Last two branches
■■ Tensor veli palatini carry all sensations
Motor nucleus: ■■ Tensor tympani from upper, lower lip,
medial to chief ■■ Mylohyoid jaws, teeth, gingiva,
sensory nucleus ■■ Anterior belly digastric floor of mouth anterior
two-thirds tongue
(except taste) cheeks,
nasopharynx, hard
and soft palate
Facial Motor nucleus Motor branches: Secretomotor to: Carries taste
(VII) ■■ For SVE fibers ■■ Muscles of facial ■■ Lacrimal sensation
■■ Salivatory expression gland from anterior
nucleus and ■■ Buccinator ■■ Sublingual two-third
lacrimal nucleus ■■ Posterior belly of gland of tongue
for GVE fibers digastric ■■ Submandibu­ via chorda
■■ Solitary nucleus ■■ Platysma lar gland tympani
for SVA fibers ■■ Stapedius ■■ Nasal and and from
■■ Stylohyoid palatal soft palate
mucosa via greater
Glossopharyngeal ■■ Nucleus ambi­ Motor branch to stylo­ Secretomotor to Carries taste Carries sensations
(IX) guous for SVE pharyngeus parotid gland sensa­ from posterior
fibers tion from two-thirds of
■■ Inferior saliva­ posterior tongue, faucial
tory nucleus for two-thirds of pillars,
GVE fibers tongue palatine ­tonsils,
■■ Spinal trigemi­ oropharynx
nal nucleus for
GSA fibers
■■ Solitary nucleus
for SVA fibers
Vagus ■■ Dorsal nucleus Motor branches Parasympathetic Taste from Sensory branches :
(X) of vagus for GVE ■■ Pharyngeal branch: motor to thorax epiglottis ■■ Pharyngeal—
fibers All muscles of soft and abdomen mucosa of pal­
■■ Special palate except tensor ate, pharynx
visceral efferent veli palatini ■■ Internal branch
fibers originate of superior laryn­
from nucleus geal nerve—
ambi­guous and mucosa of
Chapter 4: Physiology of Swallowing

coronal root of ■■ Pharyngeal branch: laryngopharynx,
accessory nerve All muscles of pharynx supraglottis,
■■ Solitary nucleus except stylopharyn­ above the vocal
for SVA fibers geus folds
■■ Recurrent ■■ Recurrent laryn­
Laryngeal branch. geal nerve—
All intrinsic laryngeal mucosa below
muscles vocal folds,
■■ Superior subglottis,
Laryngeal mucosa of infe­
nerve rior constrictor
Section 1: History and Basic Sciences

■■ External branch and esophagus

Cricothyroid ■■ Esophageal
Cricopharyngeus branch
Hypoglossal Hypoglossal ■■ All
(XII) nucleus (motor) intrinsic
of tongue
■■ Extrinsic

(GSE: General somatic efferent; GVE: General visceral efferent; GSA: General somatic afferent; GVA: General visceral afferent;
SVA: Special visceral afferent; SVE: Special visceral efferent).
Chapter 4: Physiology of Swallowing 47

Figs. 22A and B: Cortical and supramedullary centers.

Table 3: Cortical and supramedullary structures involved in swallowing.

Region Function
Lateral precentral gyrus/secondary motor area Primary motor cortex for representation of swallowing musculature
Lateral postcentral gyrus/secondary sensory area Processing oropharyngeal sensory inputs
Anterior cingulate cortex ■■ Sensorimotor planning.
■■ Important for automatic or volitional swallow
■■ Taste and smell individually
Loop of premotor cortex-parietal cortex Swallowing movement sequence planning and implementation
Loop of Broca’s area/frontal operculum—sensory cortex, Integrates sensory information about the bolus properties with the
corpus callosum, basal ganglia, and thalamus ­internal representation of swallow/taste
Insula (inferior frontal/orbitofrontal) Integrates input and output within and across hemispheres mediates
flavor (taste and smell)
Amygdala Smell (receives inputs from olfactory bulb and sends to hypothalamus)
Hypothalamus Olfactory inputs via amygdala
Fullness, thirst and satiety
Cerebellum Inhibitory influences
Coordination and timing of motor activity
Periaqueductal gray matter Responsible for inhibitory impulses from pons and reticular formation

food, thirst, hunger and electrolyte imbalance all play a of muscles with respect to force and duration required for
key role (cognitive, psychosocial, and somatoaesthetic) mastication and judging cohesiveness prior to its propul­
in this phase.10,19,22 These inputs are important not only in sion.13,22
initiating the salivary flow but also dictate the muscular With solids, lips are closed (orbicularis oris) and the
adjustments for appropriately receiving the bolus (e.g. jaw solid food is moved from the anterior oral cavity to the
opening or tongue lowering).23,24 post-canine region for chewing (also known as stage 1
In bolus preparation, afferent sensory inputs regard­ transport).12 It is pushed between the teeth repeatedly
ing tactile stimuli (bolus volumes, pressure and viscosity), by the tongue medially (intrinsic and extrinsic muscles)
chemical stimuli (water, taste, other solutions, cations, and cheek laterally (buccinators) in shift cycles (side
and anions) thermal stimuli (temperature), or combined balancing, aggregation and segregation) while being broken
stimuli sent via I/V/VII /IX CN, to higher centers (cortex, down into finer particles, moved around and mixed with
midbrain and medulla) to modulate the sequential activity saliva forming a cohesive bolus.13
48 Section 1: History and Basic Sciences

Fig. 24: Central pattern generator in medulla.

DSG (dorsomedial swallowing group near Nucleus tractus solitari-
us) activates the VSG (ventral swallowing group in ventrolateral
medulla, adjacent to Nucleus Ambiguus). VSG drives the motor-
Fig. 23: Cranial nerve nuclei in swallowing, nuclei. (Blue: Sensory, neuron pools of the cranial nerves V, VII, IX, X, XII, C1–3. for
Red: Motor). executing the swallow.

This processing of food by chewing involves rhyth­ Bolus when perceived as appropriate to swallow by its
mic, cyclical jaw opening (suprahyoid muscles—anterior cohesiveness,13 is loaded in a groove on the dorsum of the
and posterior belly digastric and mylohyoid), and closing tongue or under it in the sublingual space ready for pro­
movements (muscles of mastication—masseter, medial pulsion.1,12
and lateral pterygoids, temporalis), acting synchronously
with vertical lateral and anteroposterior excursions of the Oral Propulsive Phase
tongue and soft palate in coordination with respiratory
changes. Air movement associated with jaw movements Tongue plays an important role during this phase.
also delivers aroma of the chewed food to nasal chemore­ With the lips sealed, the soft palate is first elevated
ceptors through the fauces.10,12 (levator and tensor veli palatini) and contracted poste­
With liquids, the bolus is held between tongue, hard riorly preventing nasal regurgitation.17
palate and dental arches. The soft palate is tensed, lowered Then, with hyoid elevation (Mylohyiod) described as
(tensor veli palate, palatoglossus), back of the tongue the leading complex,1 the tongue is raised at the tip and
raised (styloglossus, palatopharyngeus) posteriorly sealing laterally (Superior longitudinal muscle/Genioglossus)
the fauces and preventing leak.17 and its base lowered (Hyoglossus) in the more common
In contrast, with solids, due to constant movements of tipper type of swallow. To scoop food stored under the
the soft palate and tongue while chewing, softened bolus tongue, an initial lowering movement is seen as in the
may partly be moved to the vallecullae while mastication dipper type of swallow.1 An anteroposterior wave of con­
continues (also known as stage 2 transport).12 Duration of traction in the tongue (intrinsic and extrinsic muscles)
bolus aggregation in the oropharynx ranges from a fraction squeezes the bolus against the hard palate posteriorly
of a second to about ten seconds, and has substantial and in the middle, in a piston like action. A forceful thrust
variation depending on food consistency and inter indivi­ of the tongue base towards the posterior pharyngeal
dual variation.12,21,24 wall is pivotal in completing transfer of bolus into the
With complex food containing both liquid and solid pharynx.6,25
the leading edge (liquid component) of the food often Gravity plays no role in this phase.12 Oral seal is main­
reached the hypopharynx before swallow initiation, also tained and the jaw is kept stabilized (suprahyoid muscles
seen with sequential drinking and saliva swallows.12,14, 24 and muscles of mastication) throughout this stage.17
Chapter 4: Physiology of Swallowing 49

Pharyngeal Phase incoming solid boluses pass over it while liquids

diverge around it to enter the pyriform fossae.13.
The pharyngeal phase is involuntary and characterized by 3. Glottic closure—A layered purse string closure of the
extremely rapid transit of bolus from the pharynx to the laryngeal inlet occurs by approximation of the rising
esophagus. Bolus moves at the speed of 9–25 cm/s within aryepiglottic folds and converging arytenoids (aryepi­
1 second.17 glotticus, interarytenoideus) to the base of the epiglottis.7
It consists of two main events, bolus propulsion and Vocal cords adduct (thyroarytenoideus, lateral crico­
airway protection. arytenoideus) though rarely completely28 and false
Pharyngeal swallow is triggered when the bolus is trans­ cords almost never adduct.8
ported past sensory receptors identified at various points 4. Respiration is halted mostly in expriation by a centrally
like anterior faucial arches, tongue base, epiglottis, valle­ mediated deglutition apnea 0.19 sec before laryngeal
culae, hypopharynx, pyriform sinuses, even the larynx
itself.22 Initially subject to modification by supramedul­
5. A stripping wave of segmental contraction in the cons­
lary influences, once bolus reaches areas supplied by the
trictors1,27 (superior, middle and inferior) propels the
Superior laryngeal nerve26 or with a Summation of affe­
bolus downwards into the UES, which is relaxed by
rents together,13 cortical control cannot be maintained and
a preceding centrally mediated inhibition of crico­
swallowing becomes reflexive. From the pharynx, a dense
network of sensory fibers, sensory nerve endings and
Opening of the UES is further completed by traction on
mechanoreceptors provide inputs that not only trigger the
the cricoid caused by the hyolaryngeal elevation, stretching
pharyngeal swallow but also regulate it with respect to mus­
the already relaxed UES widely open and the mechanical
cle activity and duration of sequences as well as ensuring
pressure of the bolus itself.6,16
coordinated glottic closure and other protective reflexes.18,22
Muscles of the jaw and the tongue remain contracted
The elevated soft palate maintains the nasopharyngeal
throughout to stabilize them.17
seal and a hyolaryngeal excursion occurs.17
The anterior (0.75 cm) movement of the hyoid by the
suprahyoid muscles (geniohyoid, mylohyoid, stylohyoid,
Esophageal Phase
hyoglossus, and the anterior belly of digastric muscle com­ Once bolus enters the esophagus, the UES contracts with
prising the anterior muscular sling) contributes mainly to twice its resting force before returning to its state of tonic
opening of the UES and superior (2.5 cm) by the infrahyoid contraction.16 The soft palate relaxes and larynx is lowered.
(thyrohyoid along with the long pharyngeal muscles com­ (Depressors of the palate and infrahyoid muscles).17
prising the posterior sling) to the epiglottic deflection.1,6 The bolus is propelled distally in the esophagus by
As the hyoid elevates, various airway protective mecha­ a wave of primary peristalsis at a speed of 3–4 cm/sec.
nisms are initiated and the bolus is propelled downwards This is further assisted by gravity in an upright position.12
into the esophagus. Retained food not cleared by the primary wave or from
Although exact temporal sequence of these events is refluxed gastric contents is cleared by secondary peristalsis.
still unclear, most likely, glottic closure is initiated early in As the bolus arrives in the distal esophagus, the LES opens
the swallow sequence, and maintained until completion of and the bolus enters the stomach. This transit takes place
bolus transit.8 in 8–15 seconds and is faster with liquids15 (Figs. 25 to 28).
1. Pharynx elevates, shortens, dilates (the elevators of
pharynx—stylopharyngeus, salpingopharyngeus, pala­
topharyngeus contract and the constrictors relax)
creating a hypopharyngeal sump that engulfs the Swallowing is partly volitional and partly autonomic,
downcoming bolus.6,27 i.e. swallowing can be initiated by cortical stimulation,
2. Epiglottic retroversion—Due to combined biomecha­ voluntarily eating or reflexly by sensory stimulation of
nical effect of hyolaryngeal elevation, downward bolus oropharyngeal, laryngeal mucosa by presence of food,
movement, and tongue base retraction (geniohyoid/ saliva.18, 22, 30
mylohyoid/hyoglossus), the epiglottis folds down to Although swallowing is recognized to be a central
horizontal then further below, (hyoepigloticus, thyro­ pattern generator (CPG) mediated motor response, i.e one
epigloticus) closing over the laryngeal inlet.1,7 The which can be overridden and modulated by either cortical
50 Section 1: History and Basic Sciences

Fig. 25: Oral phase of swallowing. Fig. 26: Oral propulsive phase of swallowing.

Fig. 27: Pharyngeal phase of swallowing. Fig. 28: Esophageal phase of swallowing.

or sensory inputs, once the bolus reaches a critical point swallow strategies during the oropharyngeal phase.20 Cor­
swallowing becomes a reflex, i.e. once triggered it cannot tical representation of swallowing is bilateral, however
be stopped.18,19 asymmetrical, with the dominant swallowing hemisphere
being independent of handedness.2,31 Areas are stimu­
Cortical control lated in clusters with excitatory or inhibitory neuronal
Cerebral cortex is responsible for initiation of swallow, influences. Inhibitory signals are important in preventing
synchronizing multiple supramedullary inputs in ­planning premature trigger of the pharyngeal swallow response.18,19
Chapter 4: Physiology of Swallowing 51

Although swallowing can take place in the absence of

cortical inputs,18,22, 30 injury to the cortex or its connections
to the brainstem results in dysfunction or absence of all pre­
paratory and voluntary motor sequences (swallow apraxia)
and thus plays a far consequential role than thought.19,31

Swallowing Central Pattern

Generator Control
Both the rhythmic responses and sequential motor beha­
vior are formed, organized and executed by the swal­
lowing CPG in the medulla. They consist of sequential,
programmed rostrocaudal inhibitory and excitatory
impulses which parallels the rostrocaudal anatomy of the
swallowing tract for seamless swallowing. Separate sub
networks for oropharyngeal and esophageal control, each
mediating the patterning of the respective phase of deglu­
tition have been considered.18
Interneurons mediate between afferent sensory inputs Fig. 29: Coordination with other brainstem central pattern generators.
via nucleus of tractus solitarius (NTS) to dorsal swallow­
ing group (DSG) neurons, processes them, then send
commands to the NA and hypoglossal nucleus via ventral The swallow respiratory temporal coordination varies
swallowing group (VSG) neurons to allocate appropriate with conditions like volition, manner of ingestion, body
efferent motor sequences and coordinate oropharyn­ position, and bolus volume, consistency, age (infancy
geal with the esophageal swallow. There is tight bilateral and old age) and diseases of respiratory and neurological
synchronization and a high level of neuronal flexibility systems.12,29,34 Hence, aging, a chaotic respiratory rhythm
within the CPG neuronal pools in the brainstem during or compromised respiration predisposes to aspiration.
execution of the swallow.32
Coordination of Swallowing with
COORDINATION WITH RESPIRATION ­Respiration, Phonation, and Mastication
During each swallow, breathing is suspended. There is Close anatomical and functional interactions between
inhibition of the diaphragm and central inhibition of above activities cause considerable overlap in CPGs
respiration (Deglutition apnea 0.5 to 1.5 seconds ) during related to all above. Complex neural interactions are
which the bolus travels safely to the esophagus.29 constantly modulated by switching neurons to synchronize
The swallowing apnea occurs almost exclusively at the these functions and insult to single area in the brainstem
final stage of expiration or early inspiration, when there is can cause multiple impairment of functions35,36 (Fig. 29).
low elastic resistance into the lungs.33 Breathing resumes
with exhalation (termed as glottal release in cervical aus­ The Cranial Nerves
cultation). This ensures a safer swallow, especially when
swallowing large boluses,33,34 and also helps in clearing out Swallowing is dependent on, integrity both of afferent
any residue thereby preventing aspiration ‘Exhale-Swallow- sensory inputs, and efferent motor outputs via 6 cranial
Exhale’ is the usually seen pattern, except in sequential nerves CN V, VII, IX, X, XII supplying the upper aerodi­
drinking, when swallowing is followed by inspiration. gestive tract. The CN I contributes by olfactory inputs with
Respiratory rhythm may be perturbed or slowed down but taste and flavor influencing cortical control via midbrain
is always followed by a resetting of respiratory pattern.12, 29 connections.10,19
The deglutition apnea and vocal folds closure are both Afferent input is being increasingly highlighted in ini­
independent mechanisms. Glottic closure is not required tiation of the swallow as well as its regulation. Absence of
for deglutition apnea and it has been recorded in anes­ input or inability to carry out motor commands affects
thetized, intubated even laryngectomized subjects.29,33 swallowing.22,26,31
52 Section 1: History and Basic Sciences

They also mediate various sensory reflexes that sub­

serve different functions.
1. Facilitate swallowing by chewing reflex—This is a true
reflex, triggered by the presence of bolus between the
occlusal surface of the jaw causing the jaw to drop
which leads to stretching of the masseter, causing it to
close again in turn (mediated by the V CN).37
2. Initiate swallowing—Described as one of “the most
complex stereotyped pattern of behavior that can
be consistently evoked by electrical stimulation of a
peripheral nerve.” Optimal stimuli that elicit swal­
lowing shows regional variation triggered by afferent
sensation from areas supplied by V, IX and X CN, efferent
limb via vagus nerve. (The superior laryngeal nerve
(SLN) in particular shows the lowest and most pre­
dictable thresholds, especially to dynamic stimuli and Fig. 30: Esophageal peristalsis.
water).18, 26, 22,30
3. Protective airway reflexs—For prevention or correc­
Esophagoglottal Closure Reflex (EGCR)—Abrupt eso­
tion of aspiration.30,38,39
phageal distention involving entire or various regions of
These rely on intact afferent sensation (mediated by
the esophagus causes tight adduction of both true and
IX, X, internal branch of superior laryngeal nerve (IBSLN)
false cords and preventing access to the trachea during
and Recurrent laryngeal nerve and Vagus) and their
belching, retching, and vomiting.
absence predisposes to high risk of aspiration.
The pharyngoglottal (PGUR) reflex results in increase
Laryngeal Adductor Reflex (LAR)—Laryngeal closure
in the UES pressure with pharyngeal stimulation.
reflex seen during the normal swallow.
The Esophago-UES reflexes can be either excitatory or
Pharyngoglottal Closure Reflex (PGCR)—Injection of
inhibitory and are mediated by the vagus. Distension of
small amounts of water into the pharynx induces brief vocal
the esophagus causes reflex contraction of the UES when
cord closure. Slow introduction of graded amounts causes
slow (e.g. small reflux regurgitates) and UES relaxation
partial adduction of the vocal cords, whereas rapid injection
when rapid (belching,vomiting).
results in complete closure of the cords without a swallow.
At a threshold volume, fluid in the pharynx not only
leads to glottal closure but also clears the pharynx of
Esophageal Peristalsis
any residual fluid by triggering an irrepressible swallow: Parasympathetic control through the vagus nerve regu­
isolated or reflexive pharyngeal swallow (RPS). lates esophageal peristalsis. Primary peristalsis comprises
Laryngeal Cough Reflex (LCR)—On tactile or chemi­ of a sequential relaxation in front, followed by contraction
cal stimulation of the laryngeal mucosa there is strong and behind propelling the bolus downward (Fig. 30). Secondary
involuntary adduction of the vocal folds. Triggered by stimu­ peristalsis is initiated by distension from retained food or
lus/residue in the laryngeal vestibule via CPG that causes a from refluxed gastric contents.15
series of muscle contractions, involving inspiration, com­ The esophageal phase initiated by the pharyngeal
pression (by inducing strong valvular adduction of especially swallow and regulated at the level of CPG. Sensory infor­
the False Cords) and expulsion by building up of pressure in mation carried via free vagal nerve endings mechanore­
the subglottis to expel matter from the airway effectively. ceptors (stimulated by esophageal distention, noxious
Effort closure of larynx is also seen in voluntary cough­ stimuli such as acid or heat) modulate esophageal con­
ing, straining, or eructation, urination, defecation and traction. This phase although involuntary, is not a reflexive
parturition. or all or none event. During repetitive swallowing, if a
Which type of responses, swallowing, cough, laryngo­ second swallow is initiated, it results in the immediate,
spasm or apnea occurs may depend upon where or complete inhibition of primary or secondary peristalsis
which types of receptors are activated and the intensity or and gradual decrease in esophageal contractile activity
frequency of stimulation. (deglutitive inhibition).18
Chapter 4: Physiology of Swallowing 53

Upper Esophageal Sphincter and Lower may not be carried out causing aspiration risk. This know­
ledge is important for understanding where or why limi­
Esophageal Sphincter
tations with swallowing exist in dysphagic patients and as
At rest the UES remains closed due to continuous neural to what might help them, e.g. use of modified/thickened
stimulation by the vagus plus a small passive component diets to enable safer swallowing or maneuvers/exercises
to the tone not abolished by either myotomy or vago­ that prevent aspiration.45
tomy suggesting role of strong elastic forces.16,17 Hence,
the forceful stretch caused by the hyolaryngeal elevation Development of the Human
of the cricoid, with the already relaxed UES is pivotal in ­Aerodigestive Tract and
opening of UES during each pharyngeal swallow. Extent of
Changes with Age
UES opening cricopharyngeus (0.5–1.2 seconds) is related
to bolus volume and bolus pressure.6,16 The human aerodigestive tract shows changes, that are
Factors increasing UES pressures are stress, inspiratory seen all along, from its embryological stage to birth, are
effort, valsalva, reflux and those reducing them include dramatic from birth to infancy and dynamic through
age, sleep and anesthesia.16 adulthood into old age.
The LES tone is mediated by neurotransmitters released Early embryonic period from 0 to 8 weeks is crucial for
from the myenteric plexus, vagal tone influence. During development of the branchial arches and future head and
swallowing, it is timed to relax 0.5 to 1.5 sec after the pharyn­ neck morphology and functions that originate from here.3
geal trigger by cessation of firing of excitatory and activation Their development explain the confusing multiple
of inhibitory impulses via CPG control.15,17 nerve supply to one organ, e.g. tongue and vice versa, one
Factors governing LES relaxation are deglutition and nerve supplying different structures, e.g. vagus. It also
gastric distension and TLSER (transient lower esophageal helps us understand how respiratory and digestive func­
sphincter relaxation—locally mediated spontaneous relaxa­ tions are closely related and affect each other in function
tions) not initiated by swallowing and diaphragmatic as well as dysfunction.
activity.15 Congenital syndromes arising from maldevelopment
of branchial arches appear to affect diverse structures. Yet,
these are united by embryologic origin, i.e. craniofacial
VARIATIONS IN SWALLOWING anomalies with concurrent swallowing and respiration
Physiology of swallow is extremely variable and the limits difficulties and sometimes limb abnormalities.
of what is normal depends on several variables like taste, In utero, swallowing, seen as early as 12 weeks, sucking at
texture, temperature, size, pH, odor, even familiarity, but 18–22 weeks and swallow at 34–37 weeks. This is important
most, with volume and manner of consumption. They pre­ for the regulation of amniotic fluid volume, composition,
dictably affect the timing, the temporal sequence, strength, recirculation, and maturation of the fetal gastrointestinal
duration of motor events and their timing with respiration. tract.38,46
Sensory information is received and processed to execute The second trimester sees the epiglottis soft palate
a swallow that is customized, literally for each bolus or interlock, essentially separating respiratory from the alimen­
mouthful.19,22 tary as seen in newborn, enabling simultaneous suckling
Swallowing is more of a continuous process than dis­ and breathing at birth.3
crete, and as more work got published on sequential swal­ Despite this, even in neonates, with swallowing, res­
lowing, a much wider spectrum of normal swallowing piration uniformly pauses (Apneic period seen). It is
behavior has emerged. synchronized with respiration (each swallow is followed by
Table 4 looks at some of these parameters indivi­ expiration). The pattern observed is suck-swallow-breath
dually.12,14, 21-24, 27,33, 40-45 in the ratio 1:1:1 at the start of feeds with mild saturation
Besides each person has his or her own average that recovers quickly.47,48
mouthful and individual swallow pattern which must be All this requires significant coordination. The large
accounted for.40 What must be remembered however, is intraoral tongue and the small pharynx (Fig. 31) not only
that these are normal adjustments seen in healthy people. severely limit vocalization, but make oral respiration more
With disease or certain disorders, e.g. neurological disor­ effortful. Hence, although mouth breathing is possible, it
ders, musculoskeletal issues, respiratory problems, they is essential that nose breathing be intact in the newborn.3
54 Section 1: History and Basic Sciences

Table 4: Variations of swallow and parameters affecting it.

Bolus parameter Sequence Comment
Large single liquid bolus ■■ Increased force for propulsion ■■ As pharyngeal clearance time remains
20–30 mL - (an average mouth ■■ Increased bolus velocity same
full is 15 mL approximately for ■■ Increased laryngeal closure ■■ Large boluses stress musculature in
an adult). ■■ Increased apneic period compromised or dysfunctional states
■■ Greater hyolaryngeal excursion
■■ Increased UES opening time
Smaller single bolus liquid ■■ Pharyngeal clearance may begin before swal­ ■■ Risk for aspiration is decided by the
sips 5 mL lowing reflex is triggered location of the bolus at time of trigger
■■ Exact location of bolus at that time is often ■■ Afferent inputs critical for safety/risk of
below vallecula airway
Continuous or sequential swal­ ■■ Partial activation and deactivation of all muscles ■■ Is more the norm in routine life
low from cup from suprahyoid to laryngeal muscles ■■ Rhythmic/reflexive cycles before eso­
Sip size depends on cup size ■■ Repeated cycles of lingual propulsion, velo­ phageal swallow
23–27 mL pharyngeal closure, and hyolaryngeal elevation. ■■ With multiple, successive swallows, the
■■ Accumulation in pyriform fossa, valleculae ­esophagus remains inhibited until the
between triggers last swallow which is followed by peri­
■■ Trigger after multiple swallows staltic contraction (deglutitive inhibition)
■■ Partial penetration accumulated in pharynx with
clearance at next swallow.
Straw drinking ■■ Accumulation in vallecula common before ■■ Requires significant oropharyngeal
Mean volume 11 mL ­trigger coordination
■■ Delayed trigger is routine ■■ Greater risk of aspiration
Saliva swallows (1–2 mL) ■■ Reflexly triggered ■■ Unanticipated
Almost 1 per minute ■■ Frequently after accumulation in valleculae or ■■ Intact neuromuscular coordination/
pyriform fossa intact sensation is important
■■ Partial adduction of vocal folds ■■ Increased threshold volume or rapid
accumulation can be risk for aspiartion
With large solid boluses ■■ Increased bolus preparation time (9–20 sec) Risk for aspiration is not always decided
depending on volume/texture/temperature/size by the location of the bolus at time of trig­
of mouth ger valleculae/pyriform fossae as thought
■■ Partially prepared bolus is accumulated on the earlier
dorsum of the tongue or in vallecula is common
before trigger
Thickened fluids ■■ Increased oropharyngeal muscle force and ■■ Viscosity changes with speed of transit/
transit time temperature
■■ Triggers/Initiates the swallow ■■ Slows pharyngeal phase so safer with
■■ Laryngeal closure unaffected aspiration risk.
Temperature ■■ Liquids can be consumed at higher tempera­ ■■ Clinical implications in diagnosis/loca­
Taste tures tion of lesion
Smell/flavor ■■ Affects the phases of swallowing ■■ Therapeutic considerations. and appli­
Carbonated fluids ■■ Stimulate swallow sour/sweet/cold cations
■■ Hyposmia/noxious/unfamiliar delays trigger
■■ Trigger swallow

Cough is not particularly well developed and epiglottic is achieved by the relatively large arytenoids, true cords
tilting is not observed during swallowing. Airway protection approximation and reflex apnea.48,49
Chapter 4: Physiology of Swallowing 55

From 3–6 years, mastication and jaw movements

become more developed and mature. By 7 years, the
larynx descends to C3-C5 level and further drops to C6-C7
level by adulthood. Changes after that are more internal
and the function related to swallowing stays fairly stable
till middle age.51
After age of 45 years swallowing slows down gradually.
Cartilages have begun to ossify, joints ankylose. There is
gradual loss of elasticity in tissues and thinning and dry­
ness of mucosa.51
At 65, swallowing deteriorates significantly. Sarcopenia,
the age-related loss of skeletal muscle mass affects all
muscles involved in swallowing. Deteriorated anatomic
and physiologic parameters with atrophy and fatty infil­
Fig. 31: Oral cavity of an intant. tration of muscles, motor-unit density, reduced muscle
activity, i.e lower pressure slower waveforms and lower
resting tone leading to diminishment in strength, mobility
Teeth are not erupted, the hard palate is flatter. Nutri­
and endurance of muscles (notably of the tongue, supra­
tive suckling involves both to and fro movements of the
hyoid muscles, pharyngeal constrictors).2,52
tongue and external pressure with jaw movement, sup­
Reduced esophageal muscle tone, peristalsis and
ported by buccal pads of fat.46
mechanical obstruction due to osteophytes may affect the
By 4–6 months, sucking becomes more dominant over
esophagus. There is overall cortical atrophy with slowed
suckling.46 The hyoid descends and the epiglottis loses
neural processing, deterioration of somatosensory percep­
contact with the palate.3
tion of oral-pharyngeal sensation, reduction in number of
This period of weaning is crucial for neural rewiring,
nerve endings, nerve fibers especially that of the superior
and maturation of pharyngolaryngeal neuromuscular
laryngeal nerve results in decreased afferent inputs to the
coordination with potential respiratory instability in tran­
brain. Thirst is reduced, taste is altered and smell deterio­
sition. Also this period of transitional feeding, is critical
rates.There is decreased saliva production and changes in
and sensitive for development of alimentary behavior and
the jaws especially mandible occur with loss of teeth.52,53
failure to introduce right foods at this time can cause
All this reflects in slowing down of all phases of
maladjustment with feeding.50
At 6–9 months, gag reduces, teeth erupt, with growing swallowing.
control and strength of oropharyngeal musculature, tex­ Increased bolus preparation time, reduced tongue
tures and finger foods can be introduced. By 9–12 months, pressure, prolonged pharyngeal delayed trigger with
chopped foods, chewing, grinding is possible and better uncoupling of oral and pharyngeal phases, increased
coordination enables spoon and cup drinking.46 duration of pharyngeal swallow (decreased peristaltic
Between 18 months to 3 years the larynx descends amplitude with decreased peristaltic velocity), decreased
gradually causing major positional changes with anato­ duration of cricopharyngeal opening, decreased laryngeal
mical rearrangement of structures and their function. The excursion, delayed closure of the larynx, and increased
posterior tongue descends, forming the anterior wall of post-swallow residue and frequent laryngeal penetration.
pharynx, creating an enlarged permanent supraglottis that Esophageal transit time increases and more than one
allows for modification of sounds allowing wider range swallow is needed to clear the bolus.52-54
of vocalization. Enhanced tidal oral respiration can also However, the clinician must bear in mind that in pres­
occur.3 byphagia, characterized by changes in the mechanism of
Food and air passages now intersect and respiratory oropharyngeal and esophageal swallowing due to aging,
function is compromised during swallowing. This risk complications like pneumonia, malnutrition, and dehy­
must be compensated then by precise neuromuscular dration are not seen. But respiratory reserve also diminishes
coordination and reflexes organized at higher centers in and associated comorbid conditions and their medica­
the CNS. tions may aggravate dysphagia. Resultantly, even slight
56 Section 1: History and Basic Sciences

fatigue in illness may be sufficient to put the elderly at risk b. Exact temporal relationships between breathing, swal­
for potential aspiration.53 lowing and mechanisms of airway protection.
c. Interaction between swallowing, chewing, respiration,
CONCLUSION cough, and vomiting.
d. Defining the trigger point of swallowing—where
Swallowing is a highly coordinated, rapid sequence of
exactly does it become automatic and what factors
neuromotor behavior, partially reflex and partially under
influence it.
volitional control with two distinct components—Passage
of bolus and Protection of airway. e. Role of supramedullary influences for sensory modu­
It is dependent on integrity of anatomical structures as lation of swallowing for specific strategies by targeted
well as neural circuits. therapy in dysphagia rehabilitation.
Although a CPG related activity, neural control is f. Further studies with continuous and sequential swal­
hierarchical and sensory input is crucial to swallow lowing, larger study groups, uniformity and standardi­
programming. zation in study techniques are needed for reviewing
There is considerable overlap and integration between dysphagia behaviors as well as scrutinizing limits of
phases of swallowing with uncertainty about exact tem­ normal variation within individuals.
poral sequences of events involved.
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ing. Am J Physiol. 1990;258(5):G675-81. bolus size for thin liquids. Dysphagia. 1989;4(1):1-3.
25. Mcconnel F. Analysis of pressure generation and bolus 42. Daniels SK, Foundas AL. Swallowing physiology of sequen­
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swallowing and airway protection: a role for the inter­ Res. 2000;43(6):1481-92.
nal superior laryngeal nerve in humans. J Physiol. 2003; 44. Coster ST, Schwarz WH. Rheology and the swallow-safe
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27. Yoon KJ, Park JH, Park JH, et al. Videofluoroscopic and 45. Cichero JA, Halley PJ. Variations of the normal swallow.
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geal sphincter function during swallowing. J Neurogas­ Theory and Practice. Chichester, England/New York:
troenterol Motility. 2014;20(3):352-61. Wiley; 2006. pp. 47-91.
28. Ohmae Y, Logemann JA, Kaiser P, et al. Timing of glottic 46. Arvedson JC, Brodsky L. Pediatric swallowing and feeding:
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Clinical Assessment and Office Procedures
5. Clinical Evaluation in a Patient with a Voice Disorder
6. Stroboscopy, High-Speed Imaging, Videokymography and
Optical ­Coherence Tomography
7. Voice Analysis and Therapy Planning by an SLP
8. Clinical Evaluation in a Patient with Dysphagia with Role of FEESST, VFS and TNE
9. Imaging of the Larynx
10. Injection Laryngoplasty
11. Office-Based Vocal Fold Procedures
12. Laryngeal Electromyography in Spasmodic Dysphonia and
Overview of Spasmodic Dysphonia
Clinical Evaluation in a
Patient with a Voice Disorder

James P Thomas

INTRODUCTION Effectively, any thing that vibrates in the audible range

of humans has a voice, whether the horn in a car or lips
Clinical evaluation of the voice often consists of only two placed against a trumpet’s mouthpiece. Voice is a sound
parts, history and laryngeal endoscopy. However, after produced by vibration and amplified by resonance; no
eliciting a patient history, the astute laryngologist will vocal cords are required.
include a middle step-listening to and documenting by We can tune a wire to vibrate 150 times per second
audio recording the vocal capabilities of the patient before and we will hear a tone. On a piano, the white key at D3
pursuing the endoscopic examination. Based on the pitch vibrates at almost 150 times a second, creating an audible
and volume where dysphonia is elicited, we have gene­ vibration. The sound board of this piano resonates and
rated a vocal capabilities pattern or vocal signature. Utili­
amplifies the pitch, bringing into play various overtones
zing this pattern during the visual examination with the
from sound bouncing around within the cavity. For those
endoscope and stroboscope, viewing the vocal cords at the
of us not used to listening closely, we may not initially be
same pitch and volume as the elicited dysphonia, more
able to describe in words the voice of this particular piano.
accurately identifies the pathologic cause of hoarseness.
Yet, play the same note on a guitar string and we hear the
The patient history is an important step for identifying
same tone, but a different voice. And most of us could sepa-
the cause of a voice disorder and techniques for history
rate the voice of a guitar from a piano.
taking are well known. After obtaining a patient history,
Consequently, voice is vibration in the range of human
the astute examiner though concentrates on the second
hearing, made by a sound source and amplified by a reso­
and often missed portion of the laryngeal examination,
nating cavity. That is, something vibrates, usually vocal
eliciting hoarseness. Before describing this method of
cords in a human (but it could be the supraglottis or even
vocal testing, let us agree on some definitions.
the esophagus in a postlaryngectomy patient). Something
amplifies the sound, the pharynx. Sound is then further
DEFINITIONS altered into speech. Vowels tend to be created in the pharynx
■■ Voice and the palate, nose, tongue and mouth further alter the
■■ Hoarseness sound to create consonants and ultimately words and
Voice For the diagnosis of voice disorders, it may be helpful
to think of a speech line, a dividing line in the human neck
“What is voice?” Sound coming out of your mouth— at the top of the larynx. Below this line, voice is produced
according to a dictionary. and above this line, voice is modified to create speech. In
Is it necessarily something made by the larynx? this chapter, our attention will be below this line (Fig. 1).
Consider that a violin has a “voice”. A bow is pulled
across strings, they vibrate and the air inside the wood of
the violin resonates, amplifying the vibrations. We hear
and recognize the sound of the violin. We recognize the For most individuals, voice is a relatively clear tone manip-
voice of a violin. ulated rather freely in terms of volume and pitch. We can
62 Section 2: Clinical Assessment and Office Procedures

between oscillations. Continuous air leak through a gap

results in nonlaminar flow at or beyond the edges of the
vocal cords, generating white noise via turbulence; essen-
tially the sound produced intentionally by a whisper. Stiff
vocal cords require greater airflow to produce oscillations;
consequently some airflow passing between stiff vocal
cords is converted to turbulence. Unwanted breathiness
can be thought of as the inefficient conversion of subglottic
pressure to sound production by a volume leak (large gap)
or a pressure leak (stiffness).
Pitch is determined by tension, mass and length of
the vibrating source. Unwanted roughness may be created
anytime, there is more than one nonharmonic vibratory
source; that is to say, two (or more) different pitches gener-
Fig. 1: The general borderline between voice production and
ated simultaneously. When two vocal cords are uneven in
speech or language production.
terms of tension, mass or length, each will tend to vibrate
at a different pitch. A single vocal cord may also oscillate
also manipulate clarity, which can be thought of as the with more than one vibratory segment when there is a
intentional introduction of air leak or irregular vibrations. nonlinear density along the vocal cord length (e.g. nodule,
A patient, especially if he/she is a singer, may speci­ polyp, scar, and sulcus). Consequently asynchronous
fically complain of an impaired vocal range or impaired oscillations of each vocal cord or multiple segmental oscil-
loudness. Quite often though a patient will be less specific. lations of one vocal cord may generate multiple nonhar-
When clarity is impaired unintentionally, the patient typi- monic pitches when a difference in tension, length or mass
cally says, “I am hoarse.” exists. With two or more sound sources, competing sound
The two primary sound production impairments, waves that have no simple mathematical relationship
which constitute hoarseness, are (1) unwanted breathiness cancel and augment each other, resulting in sound with
(white noise) and (2) unwanted roughness (simultaneous irregular pitch and volume which tends to be displeasing
production of more than one pitch or polyphony). Both to the ear—roughness. A single cord that is extremely lax,
represent essentially nonharmonic passage of air through when driven with enough air pressure, may also oscillate
the sound generating system. Both terms have been in a temporal nonharmonic manner producing more than
described as significant components of vocal impairment a single pitch and is often audibly perceived as flutter,
throughout at least half a century.1-3 a severe roughness.
Unwanted breathiness*1 is created when air passes Both of these irregularities in sound production,
through the vocal cord aperture during intended pho- breathiness and roughness, are generated along the vibra-
nation, without entrainment. The most common source tory margin or edge of the true vocal cords with rare
of breathiness occurs when the vocal cords fail to close exceptions. Only in the unusual case is sound produced by

*1. While “white noise” is considered a technical term and “breathiness” could be considered a nontechnical term, breathiness
has clearly been used in voice literature for at least 5 decades. White noise has a flat spectrum over the audible frequency
range and is perceived as a /sh/ sound. Because breathiness is such a common term in laryngology literature, I will consider
white noise and breathiness as synonyms in this article.
Nearly the same can be said of the term roughness. It is a consumer-type term that has been used in laryngology literature for
decades. It represents the perceived quality of two or more tones, which are not multiples of each other. When two nonhar-
monic tones interact, the sound waves cancel and multiply with each other in terms of volume, altering our perception of the
sound. Voice loses clarity. We often use the term “diplophonia” when there are two almost distinct tones, but depending on the
spectral distance from each other, it may be difficult to perceive whether there are two tones or more and we could actually
be hearing a triplophonic sound, or more generally a polyphonic sound. In day-to-day musical terms, though, polyphony is
perceived as beautiful as when an orchestra is in tune and more than one note harmonically blends with related notes. For
this article, though, the terms roughness, diplophonia and polyphonia are used as —synonyms.
Chapter 5: Clinical Evaluation in a Patient with a Voice Disorder 63

some other structure or portion of the larynx, such as in the ranges of pitch and volume. The GRBAS scale does not
false cord phonation or aryepiglottic fold phonation and take this relationship into account. How do we take these
then the quality is substantially different, mostly lower variables into account?
in pitch given the larger mass of these structures, mostly
monotonal given the relative inability to alter tension of VOCAL CAPABILITIES
these structures. PATTERN MATCHING
HISTORY Orienting the Visual Examination
In 1981, Hirano published an overview of a consensus Vocal capabilities pattern matching as the second or
group’s findings regarding voice evaluation from the Society mid-portion of a three-part technique5 for identifying the
of Logopedics and Phoniatrics in Japan. In Chapter 6, the cause of hoarseness was first described by Robert Bastian,6
now frequently used GRBAS scale2,3 (Grade, Roughness, evolving from audibly identifying vocal swellings. A standard
Breathiness, Asthenia, and Strain) was proposed. The battery of vocal capabilities discussed below proves to be
GRBAS scale rates several vocal features using an ordinal useful in all voice disorders as it yields a vocal pattern to
4-point rating scale. “G” represents severity. “R” and “B” hoarseness and we could call this the vocal signature of
represent roughness and breathiness. “A” relates to power hoarseness.
(willingness or strength and also to fullness of upper har- Although many of the parameters in this technique
monics). “S” relates to hyperfunction. Another similar could also be measured with various types of hardware
auditory perceptual scale, the consensus auditory-percep- and software as vocal outcome assessments, the dynamic
tual evaluation of voice (CAPE-V)4 utilizes visual analog and interactive nature of eliciting vocal capabilities during
scaling for rating the parameters of overall severity, strain, a clinical examination leads to immediate decision-
roughness, breathiness, pitch, and loudness. making, which allows the examiner to probe the voice
It was felt that these scales, which end up giving and identify the etiology for the complaint of hoarseness.
a numeric rating to hoarseness, might lead the examiner Rather than a goal of extremely precise measurement, as
toward a specific pathology. The attribution of a numeric in various software packages, or even moderately precise
rating or degree of impairment for these parameters can be measurement, as in GRBAS ratings, vocal capabilities pat-
useful, perhaps over time, for intraindividual comparison. tern matching is used for recognition of an overall pattern,
However, in its present form, at least three of the ratings which then orients the following visual examination of the
are not utilized to direct the examiner towards pathology. larynx. Ideally in Part I of a patient interaction, the patient
The “G”, representing severity, does not direct the examiner. offers a history. In part II vocal capabilities are assessed.
“A” seems to relate more to the phonatory tract, e.g. the Then in Part III of a laryngology examination, vocal cords
are examined with endoscope and stroboscope, oriented
pharynx which, when tuned properly, provides resonance
filling in upper harmonics. “A” might also refer to breath by the findings from Parts I and II.
support or pulmonary or diaphragmatic function. It is
difficult to discern precisely what the authors were listen- Documentation of the Voice
ing for with the “S” ratings’ “psychoacoustic impression Vocal capabilities pattern matching is not only a sensitive
of a hyperfunctional state”. Hyperfunction seems to carry method for assessing changes in the voice; recording vocal
different meanings with different authors, ranging from an capabilities before and after any intervention that has
impression of nonorganic psychological vocal alteration to the potential for altering vocal cord function has signi­
supraglottic compensation for impaired glottic closure. ficant benefits and few negatives. For example, recording
Two of these ratings though, roughness and breathi­ vocal capabilities before surgery that could directly alter
ness are necessary components for localizing laryngeal the vocal cords (microlaryngoscopy) or indirectly (sur-
pathology, but not sufficient. The insufficiencies of the gery near the nerve supply of the larynx in the brain, skull
GRBAS scale are how roughness and breathiness correlate base, neck or chest) would provide necessary and even
with two other parameters, pitch and volume. In almost all sufficient documentation for later comparison. It might
voice disorders, roughness will change between low and not be a preposterous idea to have such a recording even
high pitch and roughness will also change between low before general anesthesia, if one wished to learn the true
and high volume. Breathiness has a similar variability over incidence of significant vocal injury following intubation.
64 Section 2: Clinical Assessment and Office Procedures

An audio recording of vocal capabilities essentially docu-

ments the vocal functional status of the larynx, including
the motor nerves, muscles and mucosal covering of the
vocal cords.
On the upside, first, the only method to go back in
time is to have already made a recording. Second, opti-
mal legal evidence that no unintentional change has
occurred during an intervention or that change had
occurred before the intervention is from a recording.
Third, physicians who operate near the recurrent and
superior laryngeal nerves would have a much better
sense of how often the nerves are injured both tempo-
rarily and permanently and could offer their patients
reasonably accurate estimates during a presurgery con-
ference as well as alter their future surgical techniques Fig. 2: Vocal capabilities pattern matching is the technique of
based on this feedback. Fourth, an audio recording is a far varying pitch and volume over a standard set of vocal tasks to
more accurate record for comparison than a physician’s document and predict vocal stroboscopic findings, perhaps utilizing
a keyboard to asses vocal pitch range and the approximate loca-
memory or written notes or even a phonetogram without
tion of dysphonias.
sound. Fifth, recording from a microphone attached to a
laptop computer takes little effort, less than 5 minutes of
time and costs are minimal. with a tone on a piano). It is not necessary to know the
A suggested method for recording an individual’s precise pitch, though there are machines and apps that
vocal capabilities are via a microphone held a set distance can do that. An approximation is adequate; indeed we
in front of the mouth. The following tasks give a relatively typically modulate our comfortable speaking pitch over
complete overview of pitch and volume capabilities: read- several notes to convey emotion. Good storytellers modu­
ing aloud, maximum phonation time (MPT), vocal range late a great deal but there will be an approximate central
(lowest and highest pitch), maximum volume, vegetative pitch. We typically use only a very small portion of our
sound, and vocal swelling tests (Fig. 2). vocal range in daily speech.
Third, the reading task allows time to hear any speech
Pitch: Comfortable Pitch: Reading Task issues. Problems with the rate of speaking or poor enun-
ciation become audible during this task. Involvement of
The patient reads aloud a paragraph using a comfortable muscles innervated by other branches of cranial nerve X
voice. Using the same passage for every examination pro- (e.g. palate) and other cranial nerves (e.g. XII, IX, and VII)
vides for easy future comparison. While reading is a mix- involved in articulation may be audible.
ture of voice and speech, reading aloud provides a rough Fourth, severe hoarseness apparent during this task
measure of “comfortable speaking pitch”. cues the astute examiner to severe breathiness or rough­
Reading often relaxes the patient and takes the focus ness present at the comfortable speaking pitch.
away from the examination—many patients start out with Fifth, if the comfortable speaking pitch is elevated
a great deal of anxiety during an examination, anticipating above the typical range for the patient’s gender, such as in
foul tasting medicine placed in the nose and throat, wor- obligate falsetto, atypical recruitment of the cricothyroid
ried how big the tube is that goes in the nose and how much muscle may be deduced.
it will hurt. These fears are not irrational, as previously When the same person performing endoscopy per-
examined patients complain of terrible tasting sprays, forms these vocal elicitations, the process of differential
uncomfortable or even painful endoscopic examina­tions diagnosis formulation begins during this vocal task and
and they may have gagged terribly. progresses during further vocal capabilities testing. The
Second, by listening, the approximate average speak- examiner begins a visual thinking process about where to
ing pitch is noted (perhaps clinically by matching the voice look for the sound impairment.
Chapter 5: Clinical Evaluation in a Patient with a Voice Disorder 65

Pitch: Comfortable Pitch: Maximum Moving lower in pitch removes any compensation
from the cricothyroid muscle. For example, a vocal paresis
­Phonation Time will become more apparent as increased air leak at lower
Using the /i/ (long e) sound, ask the patient to see how long pitches.
they can say /i/ on one breath, at their comfortable speak-
ing pitch and comfortable volume. MPT is recorded as the Pitch: Vocal Range: High Pitch
number of seconds a single phonation is maintained at a
specific pitch. MPT typically increases with higher pitch, A similar investigation is performed moving up in pitch
as less air is utilized for the shorter oscillation intervals until the patient produces the highest note they are ­capable
and the lower amplitude of oscillation releases less air. of. Typically this vocal ceiling is reached where the vocal
An increase in volume leads to a shorter MPT as more air cords, placed on a stretch, reach the limit of their ability to
passes between the cords. One method of standardization vibrate given their mass and stiffness, as well as the limit
is to try and record the MPT at the same pitch and volume of energy that subglottic airflow can impart. When the
as the comfortable speaking pitch determined during the uppermost notes have a tight quality, we could term this
reading task. While not controlling pitch and volume as a muscle-quality vocal ceiling. There are other qualities
precisely as a researcher might with computerized testing possible for a vocal ceiling. The individual may reach a note
equipment in a soundproof booth, this test, the MPT at where the voice suddenly cuts out and this can be sugges-
the comfortable speaking pitch, is a rough measure of the tive of a swelling-quality vocal ceiling caused by a sudden
degree of vocal cord approximation. dampening of vibrations when a vocal cord margin eleva-
The more closure, the less air is wasted and the longer tion touches the opposite vocal cord or they might leak air
sound can be maintained. As a rough guide, with an MPT at the highest note suggestive of a gap-quality vocal ceiling
of less than 10 seconds duration at the comfortable speak- caused by a lack of closure.
ing pitch, most people will complain of being out of breath
with talking. Healthy young people can typically go beyond Volume: Loud: Yell
20–30 seconds on MPT testing. There are many variables
that affect this test, including lung capacity as well as vocal A robust vocalization, not a scream, but a well-supported
strategies used to produce sound, but the more that the yell on the word “Hey” assesses the ability of the patient
pitch and volume are kept constant; the more the test to maintain or recruit additional closure with increased
represents vocal cord approximation. This is an especially subglottic pressure. The additional energy from increased
helpful measurement for one individual over time. For pressure beneath the vocal cords can cause weak vocal
example, after implementation of some treatment to the cords to flutter. The task may allow stiff vocal cords to
actually produce sound, when quiet sounds were almost
voice, change in MPT after the intervention is often sec-
impossible. Psychogenic problems often show up on this
ondary to the intervention.
test when the patient hesitates or exaggerates performing
Near the end of the MPT, when there is reduced breath
this task, perhaps subconsciously worrying that the voice
support, vocal impairments will be more noticeable.
will create sound in an unexpected way where there previ-
Essentially, the compensation provided by high subglot-
ously was no sound.
tic pressure diminishes and impairments such as stiffness
Vocal effort and vocal quality during high vocal inten-
and glottic gaps become more audible.
sity (volume) may be assessed at both low and high pitch.
Notation is made whether the volume seems normal,
Pitch: Vocal Range: Low Pitch reduced (typical of paralysis) or better than expected
Next, the patient attempts to produce sound at their low- (typical of bowing and termed vocal recruitment). Nota-
est pitch, at any volume, defining the vocal floor of their tion is made of volume relative to the pitch. A loud sound
voice. Sometimes the person has excellent vocal rapport, that can only be produced at high pitch is suggestive of
capable of matching their voice to notes played on a piano. weakness such as a recurrent laryngeal nerve paresis.
Some people are not so talented and the examiner may ask Notation is made of quality. A loud phonation that is clear
them to slide down in pitch and then by ear try to deter- at high pitch and causes flutter at low pitch is suggestive
mine the lowest note produced. of an anterior branch, recurrent laryngeal nerve paresis.
66 Section 2: Clinical Assessment and Office Procedures

Notation is made of patient effort. A patient with a non­ day to you,” between the words “day” and “to” is a melodic
organic voice issue will typically defer on this task or be interval of a fourth (5 semitones). If no sound comes out
surprised when their voice is suddenly normal or there on the word “to”, or if there is a significant onset delay to
may be facial signs such as la belle indifference. the start of vocal cord vibration on that word, then there
is likely some mechanical vibratory limitation of the vocal
Volume: Loud: Vegetative Sounds cords commencing within this interval of a fourth. This
test can be repeated at a lower or higher tone and the tone
Ask the patient to cough, followed by a clearing of their
where the voice cuts out more precisely determined. This
throat. These tasks can be helpful, like yelling, in sorting out
denotes the soft cutoff point.
weakness of the glottis or psychogenic/nonorganic vocal
Robert Bastian has termed this test for the soft, upper
problems. For instance, if a patient could only w ­ hisper up
vocal ceiling, the “vocal swelling test”6 and the examina-
to this point in the examination, but can produce a robust
tion is very sensitive for vocal cord vibratory margin swell-
cough, then the vocal cords or some portions of the glottis
ings (nodules and polyps). In general, the point at which
have the capacity to come together, hold back air and then
there is an onset delay or soft sound cutoff point signifies
on release, generate sound. Notation is made whether
the tension at which a swelling on one vocal cord touches
the patient can or cannot produce sound on this task and
the other vocal cord and stops cord vibration. It is just
whether it is normal, soft, seal-like bark quality or strained.
like putting your finger lightly on a vibrating guitar string,
dampening or stopping the vibration and sound.
Volume: Soft: Swelling Tests
It is also possible to learn to hear a central glottic gap
Perhaps the most detailed task, the examiner reassesses with this test. The point at which the patient cannot start the
the upper and lower ends of the vocal range at the very vocal cords vibrating (because all the air leaks out between
softest volume the patient can produce, for comparison the cords without entraining them) does not occur at as
with the previously recorded maximum vocal range. Quite precise a pitch as when a swelling stops the vibrations. But
often, this requires some coaching. There are a number of there will be a general pitch range over which the vocal
disorders that impair soft voicing and despite the patient’s cords cannot be entrained during low air flow because of
interest in solving their problem, no one likes to “fail” at the width of the glottic gap.
a test, not even a patient. This is especially pronounced in Occasionally vibratory impairment may be secondary
professional voice users. Even when an individual’s chief to compression from a mass above the vocal cord. A dilated
complaint is that they are missing notes, they utilize signi­ saccular cyst may dampen the vocal cord’s vibrations at
ficant effort to avoid sounding “bad” on these notes during certain pitches if compressed against the true vocal cord.
an examination. Coaching the patient to sing softer and Compression from the saccular cyst may also shorten the
softer and emphasizing the importance of hearing on what effective vibratory length of one vocal cord creating diplo-
tone the vocal cords stop vibrating and when the voice
sounds bad, can improve patient compliance with the test.
Emphasis is placed on hearing and discovering the hoarse
or impaired voice. CONCLUSION
Generally, a healthy larynx should be able to produce Vocal impairments can be described in terms of roughness
similar tones at both soft and loud volumes at both the and breathiness, the “R” and “B” of the GRBAS system.
upper and lower ends of their vocal pitch range. When Roughness is typically diplophonia, although other quan-
one cannot reach almost the same note softly that one can tities of multiple simultaneous pitches can be produced,
reach loudly, there is probably a vibratory impairment. all creating the perceived quality of roughness. Breathiness
The greater the difference between the soft-volume vocal is unwanted air leak or air escape between vocal cords that
pitch range and the high-volume vocal pitch range, the do not completely approximate or are stiff. However with
more significant the vocal cord vibratory problem. vocal capabilities pattern elicitation, we can be more pre-
One of the easiest ways to determine the upper limit cise than simple grading of the amount of roughness and
of the soft vocal range is to have the patient sing the first breathiness. An accurate descriptive method is noting the
four words of the nearly universally known song “Happy onset of roughness and/or breathiness as present at high
Birthday to You.” When singing the words “happy birth- pitch, low pitch or at both. We can be even more precise
Chapter 5: Clinical Evaluation in a Patient with a Voice Disorder 67

and note the specific pitch at which diplophonia begins to the status of the laryngeal muscles, the status of the closure
be produced or breathiness become significantly notice­ of the margins of the vocal cords, the flexibility of the vocal
able, and then whether or not this condition is present from cord mucosa, as well as the status of the symmetry of the
this onset pitch upward or this onset pitch downward. The vocal cords.
most accurate record is to have dated audio and video
recordings maintained for future review or comparison. REFERENCES
Utilizing the following parameters for vocal capabi­
1. Isshiki N, Okamura H, Tanabe M, et al. Differential diagno-
lities pattern matching; comfortable speaking pitch, MPT sis of hoarseness. Folia Phoniat. 1969;21:9-19.
at comfortable speaking pitch, vocal range (lowest pitch, 2. Hirano M. Clinical Examination of Voice. Vienna: Springer-
highest pitch), loudness capability, vegetative sound Verlag; 1981.
capability and vocal swelling test we can then define or 3. Dejonckere PH, Obbens C, de Moor GM, et al. Perceptual
describe the vocal signature of each patient with a com- evaluation of dysphonia: reliability and relevance. Folia
plaint of hoarseness. This vocal signature orients the phoniatrica. 1993;45(2):76-83.
4. Kempster GB, Gerratt BR, Verdolini Abbott K, et al.
examiner to the where (vocal cord margins), when (pitch
Consensus auditory-perceptual evaluation of voice: devel-
and volume) and what to observe for (gap or diplophonia)
opment of a standardized clinical protocol. American
during the third part of a laryngeal examination; laryngo­ journal of speech-language pathology/American Speech-
scopy and stroboscopy. Language-Hearing Association. 2009;18(2):124-32.
If each physician were to record the vocal capabilities 5. Thomas JP. Assessment of the Professional Voice: The
of every patient before and after interventions to the vocal Three-Part Examination. In: Bhattacharyya AK, Nerurkar
cords, and before and after interventions in the region of NK (Eds). Laryngology. Otolaryngology—Head and Neck
the recurrent laryngeal nerve, we would learn more about Surgery Series. a-12, Second Floor, Sector-2, Noida, Uttar
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Publishers Private Limited; 2014. pp. 315-23.
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Stroboscopy, High-Speed
Imaging, Videokymography and Optical
­Coherence Tomography
Soumitra Ghosh

INTRODUCTION margin, the “lower lip”, initially traverses medially. With a

progressively closing glottis a negative pressure is devel-
Dysphonia is the consequence of a number of structural, oped due to Bernoulli phenomenon which further facili-
neurological or developmental anomalies of the larynx. tates glottal closure. The closing of the vibrating vocal folds
An abnormal vibratory pattern of the vocal folds can either starts inferiorly at the area of the inferior lip and gradually
be the cause of, or the end result of a laryngeal pathology.1 propagates superiorly towards the upper lip known as
Visualizing the laryngeal function therefore is an integral “mucosal wave”. This contact area gradually increases until
part of managing a dysphonic patient. This chapter briefly the subglottic pressure reaches a significant high magni-
summarizes different imaging modalities currently prac- tude to force them apart again. The aerodynamic phenom-
ticed in diagnostic laryngology. A brief overview of newer enon of the vocal folds is known as the glottal cycle and is
diagnostic tools like videolaryngostroboscopy, high-speed repeated time and again during phonation (Fig. 1).
videoendoscopy (HSV), videokymography (VKG) and optical The vocal folds produce three basic patterns of vibra-
coherence tomography (OCT) will be provided to keep one tory patterns which are also known as vocal registers: (1)
abreast to modern technological advances in the field of modal voice, (2) falsetto voice and (3) vocal fry.
laryngology. The modal voice, commonly referred to as chest regis­
ter, is the most comfortably produced voice in terms of pitch
VIDEOSTROBOSCOPY and loudness and usually has a frequency range of about
In contrast to the standard fiber optic laryngoscopy, stro- 100–300 Hz, i.e. the mid frequency range. There is complete
boscopy enables the examiner to obtain a real-time visual glottal closure with equal open and closed phase, a promi-
estimation of vocal fold vibratory functions. It reproduces nent mucosal wave and an oval glottal configuration.
an apparent slow-motion view of the vocal fold vibratory Vocal fry or pulse register produces a very low funda-
cycle, by effectively recording successive movements mental frequency of around 30–75 Hz and has a longer
across consecutive vocal cycles. closed phase. A short and fat glottal configuration with
small mucosal waves and amplitude are the characteristic
Normal Phonation features.
Falsetto voice is an abnormally high-pitched voice
During the expiratory phase the subglottal air pressure produced mainly due to the contraction of the cricothy-
increases gradually and forces the closed vocal folds apart roid muscle. The vocal folds are thinner and elongated and
at a particular point resulting in opening up of the glottis. always maintain an open phase with small mucosal waves
The upper edge of the opening vocal fold is known as the and amplitude. This particular phonatory pattern is also
“upper lip” and initially moves away from the midline. The known as loft register or head register.
vocal folds gradually move laterally until the subglottic
pressure drops down to a significant low level. At the point
Principles of Stroboscopy
of its maximum lateral excursion, the inherent recoiling
phenomenon of the vocal folds results in gradual closing By definition, a stroboscope is a tool used to assess different
of the glottis from its lower free medial edge. This inferior phases of motion, utilizing a pulsed light source. In fiber
Chapter 6: Stroboscopy, High-Speed Imaging, Videokymography and Optical Coherence Tomography 69

Fig. 1: Successive stroboscopic images of a vocal cycle showing the different phases of phonation.
70 Section 2: Clinical Assessment and Office Procedures

Fig. 2: Illumination of the same phase of successive vocal cycles produces a still image.

Fig. 3: Illumination of different phases of successive vocal cycles produces an apparent slow pursuit motion of vocal cycles.

optic laryngoscopy, continuous illumination helps the subsequent images of shorter durations go unrecognized
examiner gather an overall impression of the vocal patho­ and are fused with successive images to produce an opti-
logy, but the subtle aerodynamic changes of the vibratory cal illusion. The fusion of these brief images by the human
cycle are missed out. The stroboscope is equipped with a brain provides us with an apparent slow motion view of
tungsten filament, which emits brief pulses of light flashes the vibratory function. This phenomenon of apparent
for microseconds to illuminate the vocal folds. These short motion is known as “Talbot’s Law” and forms the basis of
spells of bright light can be synchronized repetitively with stroboscopic theory. Few recent studies have postulated
the frequency of vocal fold vibratory cycle and can appar- that the actual scientific basis of stroboscopy is based on
ently freeze the motion to illuminate a particular phase of (i) the perception of a flicker-free, uniformly-illuminated
phonation.2 If the frequency of the flickering light is syn- image (at strobe rates above 50 Hz) and (ii) the perception
chronous with the phonatory frequency, the same phase of apparent motion from sampled images when no real
of each cycle is illuminated and a stationary picture is motion exists (at display rates above 17 Hz).3
produced (Fig. 2). This stationary phase of phonation thus
viewed can be altered according to the examiner’s discre-
tion so as to have an estimate of different phases of phona-
tion. For a standard stroboscopy recording there is a dif- The most important part of the stroboscopy assembly is
ference of 2–3 Hz between the frequency of phonation and the strobe unit which actually generates the short bursts
triggered frequency of the bulb so that subsequent phases of flickering light. The phonatory frequency and the
of the vibratory cycle gets illuminated and the examiner amplitude are picked up by a microphone and the video
perceives a slow pursuit motion of the vibratory cycle images are recorded by a high definition camera attached
(Fig. 3). to a fiberoptic laryngoscope, simultaneously. The firing
When a number of images are presented to the human of the strobe light is controlled by the examiner with the
eye, each image persists for only 200 milliseconds on the help of a foot pedal. Both the auditory and visual inputs
retina after exposure. This suggests that the human retina are recorded in the computer for assessment and future
can process and perceive only five images in a second; analysis (Fig. 4).
Chapter 6: Stroboscopy, High-Speed Imaging, Videokymography and Optical Coherence Tomography 71

Pathological conditions like shorter vibrating portion

(laryngeal web), stiffer vocal folds (carcinoma, papil-
loma, and scar), increased mass of vocal folds (polyp,
Reinke’s edema) and tightened glottis (spasmodic dys-
phonia) may decrease the amplitude. Higher subglot-
tal pressure produces increased amplitude as in loud
■■ Mucosal wave: A normal mucosal wave can be well
visualized traversing from below up and from medial
to lateral during the maximum open phase. It nor-
mally traverses approximately half of the whole width
of the visible part of the vocal folds.5 A small or absent
wave suggests any pathology in the superficial lamina
propria (polyp, cyst, sulcus, scarring, infiltrating neo-
plastic conditions). Increased mucosal waves may be
recorded in edematous lesions (Reinke’s edema) or
loud phonation.
Fig. 4: Stroboscope unit.
■■ Vibratory behavior: Normally the entire length of the
vocal folds exhibit vibratory characteristics. Any segment
showing loss of mucosal activity either periodi­cally or
Technique constantly, partially or entirely, should be documented
or assessed for pathological lesions. They may suggest an
The patient must sit in upright position, with the head and early carcinoma, papilloma or a mere scarring.
neck slightly anterior to the body (Bryce Jackson position). ■■ Supraglottic activity: Occasionally a severe muscle ten-
Topical local anesthetic agents may or may not be used sion dysphonia may give rise to supraglottal muscle
depending upon the patients demand. Ideally all sub- compression and hinder with proper visualization of
jects should be examined with both rigid (70° or 90°) and the vocal folds. Prior laryngeal manipulation may help
flexi­ble scopes. For professional voice users, assessing reducing the degree of laryngeal compression and a
the vocal function with a flexible scope is mandatory, as good stroboscopic evaluation.
holding the tongue while examining with a rigid scope ■■ Edge: The free vibrating margins of the vocal folds are
hampers connected speech; hence, the normal phona- smooth and straight, meeting with each other along
tory pattern cannot be assessed. Normally the subject is their entire length during glottal closure. Roughness
asked to say prolonged “a” and “e” for stroboscopic assess- of the edges due to any lesion, benign or malignant,
ment. Singers are asked to glide up from a lower octave interferes with the generation and unhindered prop-
to a higher octave and also to do the reverse. Professional agation of mucosal waves. Thus, the rough edges pro-
voice users are advised to either sing or speak in their pro- duced lead to air leak and subsequent hoarseness.
fessional attire during stroboscopy recording. ■■ Vertical level: Both the lower and upper lips of the
mucosal waves should meet with the corresponding
Parameters lips of the contralateral side for normal phonation. Dis-
parity in vertical level of the vibrating folds (vocal fold
The parameters of stroboscopy recordings should be palsy, arytenoid ankylosis, and scarring) can result in
standardized and the interpretation must be able to dif- significant dysphonia.
ferentiate the normal from the pathological state. As the ■■ Phase closure: A vibratory cycle comprises of open and
patient phonates the frequency and loudness are automat- closed phases, the open phase being longer than closed
ically displayed on the screen. The other parameters to be phase. The open phase is again subdivided into equal
assessed are listed below:4 parts: opening phase and closing phase. This ratio of
■■ Amplitude: It is the extent of horizontal displacement of open/closed phase duration is altered in a number of
vocal folds during phonation. Normally it is about one- situations like neurological (spasmodic dysphonia) or
third of the width of the visible part of the vocal fold. functional deficits.
72 Section 2: Clinical Assessment and Office Procedures

■■ Phase symmetry: Each vocal fold is expected to vibrate the lower lip region when the upper lip is closing. Stro-
as the mirror image of the opposite side in physio­ boscopes do not fire in too dysphonic patients where the
logical conditions. They may be termed as asymmetri­cal auditory data is weak. Stroboscope is not appropriate for
if the timing of opening, closing and degree of lateral a patient who has rapid changes in periodicity of voice.
excursion is not identical on both sides. Any change Patients with laryngeal tremor, pitch breaks and diplo-
in mechanical properties as seen in unilateral lesions phonia are also not ideal candidates for stroboscopy. In
or differences in motor control, as seen in neurologi- patients with supraglottic compression the imagery of the
cal or functional conditions can result in a significant vibrating vocal folds is hampered by the collapsing of the
amount of right-left symmetry. muscles of laryngeal inlet.
■■ Regularity: Successive apparent vibratory cycles Due to these technical drawbacks and physiological
should perform with regularity, failing which there can hindrances a number of other visualizing techniques have
be severe degree of dysphonia. Aperiodicity is due to evolved in the recent past which are discussed briefly.
imbalance between mechanical properties of VF and
aerodynamic forces as seen in: decreased pulmonary HIGH-SPEED LARYNGEAL IMAGING
reserve, muscle tension dysphonia and neuromuscu-
High-speed imaging of laryngeal vibrations, also known
lar imbalance.
as laryngeal high-speed videoendoscopy, couples rigid and
■■ Glottal closure: It is the degree of vocal fold approxi-
flexible endoscopes with highly sensitive camera sensors.
mation during maximum closure. It can be complete
The recorded data is of 24-bit RGB color images, with up to
(normal), incomplete or inconsistent depending upon
10,000 frames per second, resolution up to 800 x 600 pix-
the pathology involved.4 It can be hourglass (vocal
els, sample duration up to 32 seconds, and viewing angle
nodules), spindle shaped (presbyphonia) or incon-
as in stroboscopy.7 Recent advances in HSV are focusing
sistent (scarring). A small posterior chink is observed
on intrinsic relationships between vocal fold physiology
normally in 30% males and 70% females.6
and acoustic voice production. The main disadvantage
A considerable amount of discretion and bias have
of HSV resides in collecting and processing the massive
been reported between clinicians while reporting strobo-
amount of data generated and the time required in ana-
scopic recordings. This inter-rater discrepancy was noted
lyzing it. Hence, HSV is still regarded as an efficient device
mainly while assessing phase closure, phase symmetry
for research purpose and is yet to gain acceptance as an
and regularity of vocal folds. A universal reporting pro-
efficient medical tool in terms of validity, practicality, and
forma is of utmost importance to cut down this bias and
clinical relevance. The two areas where high-speed imag-
for uniformity in stroboscopic reporting.
ing is expected to offer new insight is about the initial voice
production and their changes with loudness and pitch var-
Advantages iation, during voice breaks and diplophonia.8
In the era of modern laryngology videostroboscopy is the
most practical and widely accepted modality for viewing VIDEOKYMOGRAPHY
the vibratory pattern of the vocal folds worldwide. Strobo-
scopic recordings are easy to preserve, use and interpret. Videokymography is an advanced imaging technique
which assesses the dynamics of vocal fold vibrations
It gives good visual feedback to the patients, both in the
using high-speed digital cameras. This unique tool was
adults and pediatric population and can be used for early
invented by Jan G Švec from Czechoslovakia and Harm K
and accurate detection of glottal pathology. Pre-/post­
Schutte from Holland in 1994.9 The high definition modi­
interventional and oncologic follow-up in detecting early
fied video camera is capable of recording frames both at
recurrence are other very important advantages of this
normal speed (50 images/sec) and high-speed (about
unique invention.
8,000 images/sec) modes. The camera selects one active
horizontal line (transverse to the glottis) from the whole
Disadvantages laryngeal image while recording in the high-speed mode.
In spite of all these advantages stroboscopy does not rep- The successive line images are observed in real time on the
resent the actual vibratory cycle. It highlights the supe- monitor, filling each video frame from above ­downwards.
rior surface of vocal folds only and is unable to evaluate These recorded images help in evaluating vocal fold
Chapter 6: Stroboscopy, High-Speed Imaging, Videokymography and Optical Coherence Tomography 73


Figs. 5A to C: (A) Male videokymograph recording. (B) Female videokymograph recording. (C) Screenshot of a videokymograph
Courtesy: K Young, Derby Voice Clinic, UK.

dynamics like left-right symmetry, open/close phase pro- in terms of producing an average of vocal fold vibrations
portion, propagation of mucosal waves and dynamics of and its inability to visualize the undersurface of a closing
the upper and lower lips of the vocal folds (Figs. 5A to C). glottis. Videokymography is capable in reproducing vibra-
In spite of being widely accepted as a universal diagnos- tory cycles in real time through the use of its high-speed
tic tool in laryngology, videostroboscopy has its limitations imaging and can pick up irregular vibratory patterns. This
74 Section 2: Clinical Assessment and Office Procedures

makes it an ideal complementary tool to video­stroboscopy degree of basal membrane infiltration and the transition
to assess a dysphonic patient.10 zones at the margins of the tumor in laryngeal cancer,
Recent researches have come up with a new form of which eliminates the necessity of a tissue biopsy and its
videokymographic visualization known as “depth kymog- morbidities.18 It can also achieve surgical control to obtain
raphy”. In contrast to the two-dimensional standard video­ disease free tumor margins during laser surgery for early
kymography, depth kymography is a three-dimensional laryngeal carcinoma.19
imaging modality that registers vocal fold movements in Subglottal edema and collagen deposition can also be
the horizontal and the vertical planes, time being the third discriminated successfully with OCT.20
dimension. This brings direction and focus to the develop- Thus, OCT has been proved to be a potent noninvasive
ment of another detailed and analytical form of vocal fold tool in diagnosing and treating both benign and malignant
visualization that is potentially an evolution of videoky- laryngopathies.15,18,21-25
OPTICAL COHERENCE TOMOGRAPHY ■■ Videostroboscopy is the most widely accepted modal-
Optical coherence tomography is a unique imaging tech- ity for viewing the vocal folds. It reproduces a real-time
nique which yields high definition two-dimensional visual estimation of vocal fold vibratory functions.
imagery of tissues at microscopic level. This relatively new, ■■ High-speed imaging provides insight about initiation
noninvasive imaging modality uses infrared light to differ- of voice production, changes during voice breaks and
entiate between normal and pathological microanatomy. diplophonia.
Though the initial contributions were restricted to the field ■■ Videokymography assesses vocal fold dynamics: left-
of ophthalmology, later on OCT found its applications in right symmetry, open/close phase proportion, propa-
almost all fields of medicine; namely cardiology, pulmo- gation of mucosal waves and the upper/lower lips of
nology, otolaryngology, dermatology, gastroenterology, vocal folds.
urology and even in neurology.12 ■■ Optical coherence tomography can evaluate the
Technically, a low coherence infrared light is projected abnormalities of the ultrastructure of vocal folds.
on the target tissue and the magnitude and phase of light
reflected back from different tissue depths is measured. REFERENCES
The tissue penetration is usually around 2 mm and the axial
1. Hirano M, Bless DM. Videostroboscopic examination of the
resolution is at the level of 10 µm.13,14 The beam is delivered
larynx. San Diego: Whurr Publishers; 1993. p. 1.
through a probe, which is usually introduced through the 2. Woo P. Stroboscopy. San Diego: Plural Publishing; 2010. p. 11.
nose, and photographs are taken with the patient awake. 3. Mehta DD, Deliyski DD, Hillman RE. Commentary on why
This technology has also been successfully coupled with laryngeal stroboscopy really works: Clarifying miscon-
rigid laryngoscopes and operating microscopes to visual- ceptions surrounding Talbot’s law and the persistence of
ize different areas of larynx, but resolutions of these pic- vision. J Speech Lang Hear Res. 2010;53:1263-7. 
4. Mehta DD, Hillman RE. Current role of stroboscopy in
tures are relatively poor. laryngeal imaging. Curr Opin Otolaryngol Head Neck Surg.
Optical coherence tomography images have success- 2012;20(6):429-36. 
fully demonstrated the ultrastructure of vocal folds (blood 5. Hirano M, Bless DM. Videostroboscopic examination of the
vessels, glands, cysts and the average epithelial thickness)15 larynx. San Diego:Whurr Publishers; 1993. pp. 112-4.
and different areas of the larynx. These pictures have suc- 6. Woo P. Stroboscopy. San Diego: Plural Publishing; 2010. p.
cessfully corroborated to the postoperative histopathology
7. Deliyski DD, Hillman RE. State of the art laryngeal imaging:
reports.16 research and clinical implications. Curr Opin Otolaryngol
Early detection and implementation of adequate treat- Head Neck Surg. 2010;18:147-52.
ment strategies are the key factors for successfully treating 8. Woo P. Stroboscopy. San Diego: Plural Publishing; 2010. p. 57.
laryngeal cancers. Simple clinical examinations, even in 9. Svec J, Schutte H. Videokymography: High-speed line scan-
ning of vocal fold vibration. J Voice. 1996;10:201-5.
the form of direct laryngoscopy, can identify premalignant
10. Aronson AE, Bless DM. “Indirect Laryngoscopy”, Clinical
laryngeal lesions in most of the situations. But adequate Voice Disorders. New York: Thieme; 2009.
information about the degree of dysplasia is not always 11. De Mul, Frits FM, Nibu AG, et al. Depth-kymography of
obtained without a tissue biopsy.17 OCT can identify the Vocal Fold Vibrations: Part II. Simulations and Direct
Chapter 6: Stroboscopy, High-Speed Imaging, Videokymography and Optical Coherence Tomography 75

Comparisons with 3D Profile Measurements. Phys Med 19. Shakhov AV, Terentjeva AB, Kamensky VA, et al. Optical
Biol. 2009;54(13):3955-77. coherence tomography monitoring for laser surgery of
12. Marc R, Paul S, Mauricio Di S, et al. Optical coher- laryngeal carcinoma. J Surg Oncol. 2001;77:253-8.
ence tomography applications in otolaryngology. Acta 20. Karamzadeh AM, Jackson R, Guo S, et al. Characterization
Otorrinolaringol Esp. 2009;60(5):357-63 of submucosal lesions using optical coherence tomography
13. Zagaynova E, Gladkova ND, Shakhov A, et al. Optical coher- in the rabbit subglottis. Arch Otolaryngol Head Neck Surg.
ence tomography: Potentialities in clinical practice. Proc 2005;131:499-504.
SPIE. 2004;5474:103-14. 21. Luerssen K, Lubatschowski H, Gasse H, et al. Optical char-
14. Sepehr A, Djalilian HR, Chang JE, et al. Optical coher- acterization of vocal folds with optical coherence tomogra-
ence tomography of the cochlea in the porcine model. phy. Proc SPIE. 2005;5686:328-32.
Laryngoscope. 2008;118:1449-51. 22. Klein AM, Pierce MC, Zeitels SM, et al. Imaging the human
15. Wong BJ, Jackson RP, Guo S, et al. In vivo optical coherence vocal folds in vivo with optical coherence tomography:
tomography of the human larynx: Normative and benign A preliminary experience. Ann Otol Rhinol Laryngol.
pathology in 82 patients. Laryngoscope. 2005;115:1904-11. 2006;115:277-84.
16. Shakhov A, Terentjeva A, Gladkova ND, et al. Capabilities 23. Burns JA, Zeitels SM, Anderson RR, et al. Imaging the
of optical coherence tomography in laryngology. Proc SPIE. mucosa of the human vocal fold with optical coherence
1999;3590:250-60. tomography. Ann Otol Rhinol Laryngol. 2005;114:671-6.
17. Bibas AG, Podoleanu AG, Cucu RG, et al. Optical coherence 24. Kraft M, Luerssen K, Lubat schowski H, et al. Technique of
tomography in otolaryngology: Original results and review optical coherence tomography of the larynx during micro-
of the literature. Proc SPIE. 2004;5312:190-5. laryngoscopy. Laryngoscope. 2007;117:950-2.
18. Armstrong WB, Ridgway JM, Vokes DE, et al. Optical 25. Bibas AG, Podoleanu AG, Cucu RG, et al. 3-D optical coher-
coherence tomography of laryngeal cancer. Laryngoscope. ence tomography of the laryngeal mucosa. Clin Otolaryngol
2006;116:1107-13. Allied Sci. 2004;29:713-20.
Voice Analysis and Therapy
Planning by an SLP

Kate Young


The treatment of voice disorders by speech and language A patient with voice difficulties will usually present to their
therapists (SLTs) has continued to develop over the last general practitioner who is unable to provide t­reatment
30–40 years. The research advances in voice therapy have to resolve the voice problem and then refer to the ENT
provided an evidence base for functional exercises and (ear-nose-throat) surgeon. It is essential that all voice
voice production techniques as treatment options to patients be seen by ENT initially to identify the nature of
change vocal behaviors. Improvements in voice therapy the voice disorder. Even if the individual works in a vocally
understanding and success in treatment have led to an demanding job this may not be the underlying cause of
the voice problem. In most countries in the world voice
increased use of voice therapy to recover from surgery,
therapy is only undertaken after a full ENT assessment
prepare for surgery or where possible, avoid surgery
and view of the larynx has been obtained. An appropriate
referral letter will contact a minimum data set of infor-
Voice therapy is a specialist branch of speech and
mation for the SLT including present voice difficulties,
language therapy, which in most countries is a university-
patient’s opinion, nature of onset, previous medical history,
trained profession as an undergraduate or postgraduate. ENT and laryngeal examination, ENT management plan
Once qualified, SLTs are registered with a professional and follow-up.3
organization (Royal College of Speech and Language Following assessment and relevant investigations
Therapists in the United Kingdom or Speech Pathology the ENT surgeon is able to make an informed referral
Australia, for example). to speech-language therapy for voice assessment and
It is the responsibility of the SLT to complete a compre- management. Ideally, the ENT department will have a
hensive assessment that results in an accurate diagnosis ­laryngologist and a voice clinic that the referred patient
so that appropriate treatment is provided, and inappropri- can be triaged into for the first consultation. Usually a voice
ate treatment is avoided throughout the patient pathway.2 patient will be seen in a voice clinic as a tertiary referral.
Voice-disordered patients are frequently complex with After receiving the referral at initial appointment with
multiple factors and etiologies affecting vocal function. the voice patient, the SLT needs to be clear why the patient
Some patients may also have co-occurring swallowing dif- has been referred and the patient’s understanding of the
ficulties. appointment being recommended. At this point in the
Comprehensive assessment (physical and functional) communication discussing with the patient what voice
of the voice-disordered patient is required prior to plan- assessment and therapy entails is beneficial to manage
ning voice therapy management. Systematic assessment patient’s expectations and commitments to the process.
measurements guide management planning. This allows
the SLT to reflect on individual cases and management of VOICE ASSESSMENT
specific voice disorders. The SLT can then conduct audit The aim of voice assessment is to examine, appraise, and
and research into improved clinical practice locally in an capture appropriate information regarding the patient and
individual practice and in the wider SLT profession.2 their voice problem. Diagnosis and management p ­ lanning
Chapter 7: Voice Analysis and Therapy Planning by an SLP 77

are based on assessment findings and fundamental infor- ■■ Describing the voice
mation regarding the impact of the voice problem. A ■■ Comparing observations to standards and normal
severely dysphonic patient surprisingly may not be con- ­values
cerned with their voice quality, however, a singer with ■■ Integrating the information to determine treatment.
mild dysphonia may report being highly concerned about The protocol recommended by the Committee on
their vocal difficulties and treatment outcome.3 Phoniatrics of the European Laryngological Society is set
It is important for the assessing clinician to avoid being of minimal basic measurements suitable for all “common”
influenced inappropriately by opinions of the referring cli- voice disorders. It consists of five different aspects:
nician and the patient and to remain open minded and 1. Perception (grade, roughness, breathiness)
query all presenting details as the assessment process is 2. Videostroboscopy (closure, regularity, mucosal wave,
carried out.2 Equally the SLT needs to consider that the and symmetry)
voice-disordered patient may be presenting from a non- 3. Acoustics (jitter, shimmer, Fo-range, and softest intensity)
voice/laryngological etiology, e.g. vocal fold weakness due 4. Aerodynamics (phonation quotient)
to lung pathology. 5. Subjective rating [voice handicap index (VHI), visual
The laryngeal examination, preferably with stroboscopy analog scale].
(see Chapter on “Voice Clinic Assessment and stroboscopy”),
and voice evaluation are inseparable. As part of a full ENT
examination, all patients should have a flexible nasendo­ VOICE EVALUATION
scopy and laryngoscopy. Video laryngostroboscopy with Case History
recording facilities—flexible or rigid provides a superior
assessment to plain light nasendoscopy to assess glottic The experienced SLT working with voice-disordered
gap, regularity of cord vibration, and mucosal wave. Litera­ patients will have a standard repeatable evidence-based
ture has reported an error rate in the diagnosis of voice protocol for voice evaluation. During this stage of evalu-
disorders made in a general ENT clinic when compared to ation it is useful for the SLT to make subjective observa-
a voice clinic. This occurrence may be related to specialist tions of the patient’s voice quality, variability/stability, the
equipment and specialist assessment protocol.4 patient’s emotional state, and patient’s perception of their
The laryngologist and SLT will relate the sound of the voice problem. When the assessment has been completed,
patient’s voice to visual assessment of the voice disorder the voice clinician aims to understand the patient goals
and will be able to assess the extent the patient’s abnormal of intervention and both agree to the same management
voice quality is consistent with physical findings of disor- plan. Case history information essential to the voice ther-
dered/inefficient voice production. The role of the SLT in apy process is detailed below (Table 1).7
the voice clinic and in the wider management of surgical
voice patients has modernized and developed in paral- Patient-reported Impact
lel with the specialist voice surgeon’s (ENT) advances in
patient treatment and management. The team approach to Quality-of-life measures, usually in the form of self-
assessment, measurement, and management is essential report questionnaires (Fig. 1), enable the SLT to under-
when working with voice-disordered patients. stand the extent to which a patient feels their voice
An appreciation of the difference between “data” and problem is affecting their personal and/or work life. The
“interpretation of assessment” is important. Both are information gained is also useful to determine whether a
essential but poor assessment outcome and planning will patient will engage in voice therapy and to measure voice
result from omitting to complete both. It is not necessary outcome and progress in treatment. The information is a
to amass large quantities of data but rather to assess sys- helpful addition to case history and assessment data to
tematically and document essential vocal parameters and form an appropriate hypothesis for the voice problem.8
behaviors. There are assessment protocols that are useful Quality-of-life measures are used in specialist voice
to follow for consistency of practice.5 assessment. The more widely used questionnaires include
The basic stages of voice assessment as described by the VHI 30/10,9 reflux symptom index (RSI),10 voice symp-
Ford and Bless (1991):6 tom scale (VoiSS),11 voice-related quality of life (V-RQOL),11,12
■■ Interviewing and voice skills perceptual profile (VSPP)11. A patient who
■■ Observing scores their voice impact inappropriately high as com-
78 Section 2: Clinical Assessment and Office Procedures

Table 1: Case history information.

Feature Detail
Personal information Age, gender, occupation
Onset of dysphonia ■■ Sudden
■■ Gradual over days/weeks/months
Progression of dysphonia ■■ Improving/worsening over time
■■ Variability/consistency
■■ Episodic/intermittent
■■ Exacerbating/relieving factors
Patients main concern Voice quality/vocal stamina/change in range of volume/throat pain or discomfort/fear of
throat cancer/inability to sing/time-off-work/comments by friends or family/unconcerned
Voice use Home/work/social/performing
Previous/ongoing medical history ■■ Diagnosed medical conditions or undiagnosed medical symptoms: respiratory/neurologi-
■■ Upper respiratory tract infections: occasional/frequent
■■ Dysphagia
■■ Nasal symptoms
■■ Hearing loss
■■ Thyroid disorders
■■ Jaw/dental problems
■■ Allergies
■■ Trauma/accidents/injuries
■■ Surgery: laryngeal/other
■■ Intubation
■■ Menstrual cycle
Reflux symptoms Throat clearing/throat mucous/unpleasant taste in the mouth or throat/burning throat
Current medication Prescribed and nonprescribed
Lifestyle issues ■■ Smoking active and passive
■■ Alcohol consumption
■■ Recreational drugs
■■ Environmental irritants
■■ Weight
Vocal care ■■ Hydration
■■ Diet
■■ Caffeine intake
Stress and anxiety ■■ Family dynamics
■■ Major life events
■■ Emotional
Courtesy: Jones SM. Laryngeal Endoscopy and Voice Therapy: A Clinical Guide, pages 6-7.13

pared to the clinician’s evaluation of their voice may have of voice is an essential and equally important part of the
significant psychological overlay or poor perceptual skills voice assessment protocol as objective voice measures.
both of which will need to be addressed before surgery Psychoacoustic measures provide subjective and quali­
and/or voice therapy is offered in the treatment process. tative detail regarding voice quality and function. Some
patients present with more complex diagnoses and a period
Psychoacoustic/Subjective of “diagnostic voice therapy” can be invaluable in gaining
a better insight into a patient’s voice problem.13 For exam-
Evaluation of Voice ple, a patient is seen on videonasendoscopy to have severe
Clinicians use a range of assessments to understand the muscle tension and only a poor view of the vocal folds is
voice problem and plan management. Perceptual ­evaluation achieved due the supraglottis closing over the vocal folds.
Chapter 7: Voice Analysis and Therapy Planning by an SLP 79

Fig. 1: Derby voice clinic patient questionnaire.

Following therapy to deconstruct the supraglottic muscles, a Box 1: Voice tests.

full view can be achieved of the vocal folds at review assess-
■■ Maximum phonation time (MPT) on /ee/ seconds
ment in the voice clinic and potentially reveals lesions or
■■ Maximum phonation time on a high pitch
other vocal fold features (e.g. intracordal cysts or vocal fold ■■ Maximum phonation time on a low pitch
atrophy) obscured at the first voice clinic assessment. ■■ Glide upwards and down
The vocal features being described include: aphonic/ ■■ Number the patient can count to on one breath.
intermittent aphonia, hyperfunctional/tense, vocal fry/
creak, grating, phonatory breaks, rough, diplophonic,
instability of vocal pitch and/or volume, and pitch (appro- perceptual evaluation of voice),14 vocal profile analysis
priate, intonation, and range). protocol, GRBASI, and voice profile analysis (Box 1). The
GRBAS (grade, roughness, breathiness, asthenia, and author recommends further reading for more detailed
strain) is a widely used psychoacoustic measurement information beyond the scope of this chapter.
system. This is found referred to in the literature, can be Symptoms of nonphonatory vocal tract sounds and
taught, is quick to complete, and has good inter- and intra­ functions are helpful and in some cases essential to include
rater reliability. GRBAS is however limited in sensitivity for in a full voice assessment. These features are assessed
describing some vocal features such as consistency and subjectively and include swallowing habits and function,
smaller steps in the severity rating scale. Other subjective nasal regurgitation, hypo-/hypernasality, respiratory pat-
voice rating scales include CAPE-V (consensus auditory- terns, and cough and throat clearing habits.
80 Section 2: Clinical Assessment and Office Procedures

Objective Voice Assessment

Essential assessment includes recording laryngeal physio­
logy and vibratory patterns. Viewing the larynx and
vocal function with digital flexible or rigid stroboscopy
is described in detail elsewhere in this book. Along with
visual instrumental assessment, electroglottograph
wavegram17 (Fig. 3) provides useful additional information
about the vibratory activity of the larynx and can support
the office voice assessment by the SLT. Classifications of
functional patterns such as Morrison and Rammage19,22
are useful descriptions for referring clinicians to use as a
baseline for presentation of phonatory patterns and will
also provide the treating SLT with a clear description of the
Fig. 2: Voice assessment in theater.
laryngoscopic findings for their assessment and planning
process (Fig. 4).18
One of the simplest but still very useful objective
It is the psychoacoustic features of voice that an SLT baseline measures is taking a good quality digital voice
specializing in voice disorders is familiar with and can recording of a representative voice sample. The sample
offer their expertise in the operative theater during frame- voice tasks can be carried out posttreatment and the
work surgery, mainly medialization thyroplasty (Fig. 2). recordings are compared. Other frequently used baseline
Other objective measures can be used to assess and guide measures include aerodynamic measures such as lung
decision-making as mentioned below such as peak direct function tests, perturbation measures such as jitter, shim-
subglottic pressure.15 In the authors’ practice the following mer, and noise to harmonic ratio maximum phonation
is used in theater (see Box 1). time (MPT), and s/z ratio. More detailed assessments are
used in specialist research centers and will likely influence
Musculoskeletal and Postural future practice. The author suggests further reading along
­Assessment with this manuscript for more information.

Speech and language therapists need to be able to assess

musculoskeletal and postural habits, observe breathing
patterns at rest, in spoken and sung tasks, and make judg- Voice therapy work was recognized and carried out as
ment regarding the need for onward referral for musculo- early as the 1930s by a small number of phoniatricians,
skeletal issues that fall outside of the SLTs skills. Postural actors, and voice coaches. As the exercises and treat-
issues affecting the back, neck, shoulders, jaw, and pel- ment approaches were documented and described, 40
vis will need to be examined. There are many good texts different exercise regimes were identified. Later Boone
describing postural assessment and foundation for revised and documented around 20 exercises and func-
healthy voice production in the SLT and singing/voice tional treatment approaches, which forms the basis of
coach literature.16 The authors work closely with the voice therapy today. Voice therapy consists of treatment
specialist physiotherapy team in our center. approaches addressing as necessary, the physiologic,
Many SLTs specializing in voice in the United Kingdom symptomatic, psychological, and hygienic issues of the
have additional skills in palpation assessment of laryn- voice disorder.
geal structural alignment and inappropriate muscle Voice therapy is successful when the correct patients
function within the larynx and neck. Muscle tension and are selected and the appropriate choice of treatment is
poor alignment of laryngeal cartilages may cause voice delivered. Often voice therapy is chosen as a conserva-
disorders but may also be the result of a laryngeal problem tive first line of treatment to “buy time” before surgery is
and result from musculoskeletal compensation leading undertaken, but this is not always a clinically appropriate
to hyperfunction. intervention. Mutual goal setting with the patient based
Chapter 7: Voice Analysis and Therapy Planning by an SLP 81

Fig. 3: Electroglottographic assessment of mucosal wave.17

Fig. 4: Morrison and Rammage muscle tension classifications.19,22

82 Section 2: Clinical Assessment and Office Procedures

on the comprehensive assessment is important for clarity Box 2: Vocal hygiene principles.
around voice therapy intervention, patient expectation,
■■ Stop smoking
and commitment at the start of the therapy process. In all
■■ Avoid habitual throat clearing
cases improved laryngeal function is an essential goal with
■■ Control gastrointestinal reflux
or without structural abnormalities. ■■ Good hydration
■■ Maintain a balanced diet
Patient Selection ■■ Exercise for general health and fitness
■■ Avoid talking over background noise
Prerequisites to voice therapy include:2 ■■ Avoid whispering, rather use a confidential voice
■■ The capacity to change (physically and functionally)— ■■ Avoid menthol and throat sprays
“vocal plasticity” ■■ Warm up and cool down the voice before singing
■■ Patient motivation ■■ Avoid fumes, dust, and household sprays
■■ Adequate hearing ■■ Avoid highly acidic foods and drinks (spirits, chillies).
■■ The patience to allow time to change
■■ Timing of treatment and commitment to practice.
Voice therapy techniques aim to:
Vocal Hygiene
■■ Alter hyperfunction vocal patterns The principle of vocal hygiene is essential in voice therapy
■■ Resolve hypoadduction of vocal folds programs (Box 2).
■■ Minimize vocal abuse
■■ Optimize vocal stamina Vocal Rehabilitation
■■ Optimize voice quality
■■ Agree realistic goals for voice treatment outcome. Musculoskeletal/Laryngeal Relaxation
Voice disorders are described as organic (e.g. vocal fold
Planning paresis) or nonorganic (e.g. muscle tension dysphonia with
or without a co-occurring lesion). Voice therapy in nonor-
Voice therapy is derived from an understanding of laryn-
ganic voice problems is based on the premise that mus-
geal anatomy and physiology. It is important to determine
culoskeletal relaxation in the larynx and supporting mus-
the physical problem and the effect on the voicing system
cles will result in improved voice quality and experience
in order to start the process of repair and resolution of
of vocal effort. As the patient follows the SLTs instructions
the voice problem. A therapist must also consider how to
and rehearses efficient muscle patterns they will begin to
avoid future functional or structural voice problem recur-
alter their habitual vocal behaviors resulting in a return of
ring and enabling the patient to appreciate how the vocal
normal or a more functional voice. In organic voice prob-
difficulties developed.1
lems voice therapy techniques are aimed at compensation
and strengthening for weakness of movement and maxi-
Vocal Education and Listening Skills mizing voice function in structural or mechanical prob-
Before a voice patient is able to appreciate the changes lems such as scarring.
prescribed by the treating SLT, they will need to be edu- Specific techniques include forward or optimal reso-
cated regarding the anatomy and functional aspects nance, flow phonation, and vocal fold contact behaviors
of the larynx and voice production. The SLT will then that will influence thick/thin fold contact, glottic closure,
need to determine the auditory perceptual skills of the timing of closure, or laryngeal posture.20 For example, a
patient and if appropriate, arrange for a full hearing quick “sniff in” before starting to phonate will pull back
assessment so that the voice patient is able to listen and equal vocal fold (Figs. 5A and B). If a “sniff” is followed by
identify changes to their voice during treatment. Once a “siren” (downward glide while saying “ng”), the vocal
discharged a successful voice patient has the skills to folds will be encouraged to achieve complete adduction
perceive and self correct poor voice technique or altered along the full length of the glottis. This is a useful tech-
voice quality therefore manage their own voice problem nique in mild vocal fold paresis or asymmetrical muscle
independently. tension.
Chapter 7: Voice Analysis and Therapy Planning by an SLP 83

Figs. 5A and B: Voice clinic images of a patient with mid-right vocal fold intracordal cyst, right posterior granulation, muscle tension,
and laryngopharyngeal reflux. (A) Before five sessions voice therapy and vocal hygiene; and (B) after five sessions of voice therapy
and vocal hygiene.

Manual Therapy associated with the voice disorder and in many cases the
primary cause of the voice problem. Secondary stress or
Manual therapies are more widely used by voice therapists emotion impact is common in voice problems. Research
and are considered passive voice exercises, i.e. the larynx has been able to show that stress and emotional change is
is being moved by the SLT or patient’s hand and not by detected physiologically in the voice before any other body
active voice production techniques. These techniques can due. For example, we feel a “lump in the throat” before
be useful as a primary or adjunctive method of treatment being about to cry or when under stress.
for musculoskeletal voice problems by releasing laryngeal Speech and language therapists specializing in voice
postural habits resulting from muscle tension and allow- disorders normally have additional skills in counseling and
ing new efficient vocal behaviors to be achieved more effi- techniques such as cognitive behavioral therapy. The voice
ciently and subsequently learnt.20,21 is part of a person’s identity, and frequently in patients
who present to voice clinic describe a feeling of change in
Respiration perso­nality or significant stress for not being able to “join
Breath support and posture are essential to consider in in” as they previously did. In cases where a patient is una-
therapy design. Posture and optimized breath support are ble to make the shift from their unhelpful think habits and
frequently used in therapy and voice warms up of vocal “give up” the secondary gain of the voice problem, more
professionals. Voice onsets and coordination with breath formal psychological or counseling treatment will be
will impact on a patient’s efficiency and stamina along needed along with voice therapy to resolve the problem.
with avoiding damage resulting from hard glottal contact.
Breath support and volume work is the main component Professional Voice Users
of Lee Silverman Voice Technique, a very successful ther-
Specialist needs of the vocal performer and other profes-
apy program for Parkinson’s patients.20 Speech and lan-
sional voice users are a detailed extensive topic beyond the
guage therapist will need to refer to other specialities if
limits of this chapter. Please see the chapter on the sing-
the respiratory patterns a patient presents with fall outside
ing voice and professional voice users’. It is essential that
their skills.
the SLT has an understanding of musical and acting terms
to appreciate the professional’s description of their voice
Emotional and Psychological Considerations and their concerns. Equally it is very helpful to be able to
The voice has an essential role in communication of self. share therapeutic process with the patient’s vocal coach or
Emotional and psychological features are very often teacher with appropriate consent.
84 Section 2: Clinical Assessment and Office Procedures


­OUTCOME Vocal rehabilitation will vary from patient to patient;
Re-evaluation throughout and at the end of treatment however, in general the aim of therapy intervention is to
assists in determining perceived change of both the restore the best voice possible, for professional activities,
patient/s and the clinician/s, objective change and patient and social and family communication. The patient is the
satisfaction. If the voice change in therapy or surgical final judge of their voice outcome and acceptability. The
treatment is dramatic it is tempting to not complete post- SLT is an essential member of the Voice Team in voice
assessment, trial therapy, treating preoperatively, and
treatment outcome assessments. It is helpful to continue
supporting the ENT intraoperatively. The SLT supports
with outcome measures so that the patient represent to
the voice patient initially postoperatively with advice
the voice clinic with a return of voice difficulties. How
and follow-up, evaluation of treatment outcomes, and
will the clini­cian know whether the reappearance of voice
further voice the­rapy to complete the treatment process.
problems is due to the same voice problem or a new
For treatment to be successful the voice must sound
­problem?22,23 Post- or peritreatment reassessment is also
better, should have improved stamina and be produced
helpful to provide feedback to patients who are dissatis-
more efficiently.
fied with voice change. Being able to show a patient the
Treatment outcomes are most successful when voice
improvements made or not is helpful to determine the
therapy and other treatments such as required surgery
next management option or to reconsider a particular
are carried out at an appropriate time in the patient’s
chosen intervention. treatment pathway. It is essential that the voice patient is
compliant with voice care, involved in their therapy, and
WHEN VOICE THERAPY IS fully aware of the intended benefits and limitations of the
­UNSUCCESSFUL treatment being offered. Comprehensive voice assessment
and therapy will enhance patients’ understanding of their
Voice therapy is similar to surgery as lack of success treatment options, reduce recovery time, minimize com-
from interventions can be multifactorial. It must be used plications, and improve voice outcomes.
appropriately to enable a successful outcome. Some
issues that are not compatible with voice therapy inter-
ventions are: selecting unsuitable patients physically and
emotionally, using referrals simply due to other treat- 1. Murray T. Pre- and post-operative phonotherapy. J Singing.
ments failing (when all else fails), or prolonging therapy
2. Aronson AE. Clinical Voice Disorders, 3rd edition. New
unnecessarily.1 York: Thieme Publishing; 1990.
Voice therapy requires the patients to have adequate 3. Abitbol J. Odyssey of the Voice. San Diego, CA: Plural Pub­
functional anatomy for therapeutic maneuvers to suc- lishing Inc.; 2006.
ceed (e.g. an overly large phonatory gap is beyond even 4. McGlashan J, Fourcin A. Chapter 166: Objective evaluation
of the voice. In: Gleeson M, Clarke R (Eds). Scott-Brown’s
the most coordinated patient to use compensatory vocal Otorhinolaryngology, Head and Neck Surgery, 7th edition.
fold adduction techniques to achieve vocal fold contact). London: Hodder Arnold; 2008.
Diagnostic therapy can be useful in these cases when there 5. Thomas J. Why Is There a Frog in My Throat? A Guide to
is a discrepancy of opinion to demonstrate a more appro- Hoarseness, 1st edition. USA: James P. Thomas; 2012.
6. Ford CN, Bless DM. Phonosurgery: Assessment and Surgical
priate therapeutic pathway.
Management of Voice Disorders. New York: Raven Press
The voice therapy process is useful to allow time for Ltd.; 1991.
patients to have a better understanding of what they are 7. Mohan S, Young K, Judd O. International Laryngeal Frame­
aiming for in treatment. This time can allow the clinician work Surgery Guide, 1st edition. UK: Crompton Publishing
time to get to know the patient and their emotional well- Ltd. (in press).
8. Sherwell C. Voice Work: Art and Science in Changing
being in more detail and determine if onward referral is
Voices. West Sussex, UK: Wiley-Blackwell; 2009.
warranted as part of their management plan. Psychologi- 9. Jacobson BH, Johnson A, Grywalski C, et al. The voice
cal issues can impact significantly on successful treatment handicap index (VHI): development and validation. Am J
outcomes.24 Speech Language Pathol. 1997;6:66-70.
Chapter 7: Voice Analysis and Therapy Planning by an SLP 85

10. Belafsky PC, Postma GN, Koufmann JA. Validity and reliabi­lity 17. Seidner W, Nawka T. Aids to Voice Diagnostics: By Profes­
of the reflux symptom index (RSI). J Voice. 2002;16(2):274-7. sionals for Professions, 1st edition. Berlin: Xion GmbH; 2013.
11. Wilson JA, Webb A, Carding PN, et al. The voice system 18. Hirano M. Clinical examination of voice. In: Arnold GE,
scale (VoiSS) and the voice handicap index (VHI): a com- Winckel F, Wyke BD (Eds). Disorders of Human Com­
parison of structure and content. Clin Otolaryngol Allied munication, 5th edition. Wein, New York: Springer; 1983.
Sci. 2004;29(2):169-74. 19. Mathieson L. Greene and Mathieson’s the Voice and Its
12. Hogikyan ND, Sethuraman G. Validation of an instrument Disorders, 6th edition. London: Whurr Publishing Ltd.; 2001.
to measure voice-related quality of life (V-RQOL). J Voice. 20. Epstein R. Management of voice disorders: key principles of
1999;13:557-69. speech-language therapy. In: Bhattacharyya AK, Nerurkar
13. Jones SM. Laryngeal Endoscopy and Voice Therapy: A
NK (Eds). Otorhinolaryngology—Head and Neck Surgery
Clinical Guide. UK: Crompton Publishing Ltd.; 2016.
Series, Vol. 5. Delhi: Thieme Publishing; 2014.
14. Consensus Auditory-Perceptual Evaluation of Voice
21. Harris T, Harris S, Rubin JR, et al. The Voice Clinic Hand­
(CAPE-V). (2003). [online] Available from
uploadedFiles/members/divs/D3CAPEVprocedures.pdf book, 1st edition. London: Whurr Publishing Ltd.; 2006.
[Accessed December, 2016]. 22. Colton R, Casper J. Understanding Voice Problems: A
15. Almohizea MI, Prasad VM, Fakhoury R, et al. Using peak Physiological Perspective for Diagnosis and Treatment.
direct subglottic pressure level as an objective measure Sydney: Williams & Wilkins; 1990.
during medialization thyroplasty: a prospective study. Eur 23. Freeman M, Fawcus M. Voice Disorders and Their Manage­
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Clinical Evaluation in a Patient with Dysphagia
with Role of FEESST, VFS and TNE

Jayakumar R Menon, Manju E Issac

INTRODUCTION Box 1: The 10-item eating assessment tool (EAT-10).

Evaluation of dysphagia is a multitask team approach and Item

1. My swallowing problem has caused me to lose weight
starts with a careful history taking which points to the 2. My swallowing problem interferes with my ability to go
clue of diagnosis and followed by specific investigations. out for meals
In many a case we get a clear picture of what kind of dys‑ 3. Swallowing liquids takes extra effort
phagia we are dealing with or which stage of swallowing 4. Swallowing solids takes extra effort
is affected. It is imperative that almost all cases require 5. Swallowing pills takes extra effort
6. Swallowing is painful
investigations. Inference from the investigation helps in 7. The pleasure of eating is affected by my swallowing
adapting to therapeutic maneuvers. Here an attempt has 8. When I swallow, food sticks in my throat
been made to explain the step‑by‑step clinical evaluation 9. I cough when I eat
to reach at a conclusion, such as history taking, examina‑ 10. Swallowing is stressful.
tion and investigations.
Clinical evaluation consists of history taking, detailed
oral motor and sensory physical exam and trial swallows history (Box 1). In this inventory which is EAT-10, seven
of liquids and foods. items relate to physical area and three items relate to func‑
tional or emotional area.1
For each item a score is put from no problem (0) to
HISTORY TAKING severe problem (4).
The clinical examination starts with history taking which A large number of cases approaching dysphagia clinic
helps in the development of conclusion. So, the impor‑ are on Ryle’s tube or a feeding gastrostomy tube and will
tant clues are to note the duration of symptoms along with be looking on to the swallowing therapist with the hope of
feeding practices, amount of food consumed, type of food, having the pleasure of eating again normally.
methods of feeding, frequency of feeding which helps in Most of them are malnourished due to loss of appetite
understanding the severity of the problem. In many a case or loss of weight.
the dysphagia history is neglected so is the trial of investi‑ Those who give a short history of symptoms should
gations as well as the understanding of the type of dyspha‑ be enquired whether it is a solid food dysphagia or liquid
gia and an immediate resolution been made in the form dysphagia. A solid food dysphagia indicates an obstruc‑
of nasogastric tube. It is a terrible mistake on the part of tion and a liquid dysphagia suggests neurological prob‑
clinician to put an end to the quality of life in these patients lem. And in some cases both types of food are difficult, e.g.
when the effort of investigations or referral to a laryngolo‑ achalasia.
gist is not made. Other important points in history are drooling, pain,
The 10-item eating assessment tool (EAT-10) question‑ choking episodes, cough while taking food, nasal regurgi‑
naire, a subjective self-assessment tool, has been recently tation, hoarseness, chronic cough, symptoms of acid reflux
introduced, which we feel should be included in the disease, breathing difficulty, and stridor.
Chapter 8: Clinical Evaluation in a Patient with Dysphagia with Role of FEESST, VFS and TNE 87

Patients with neurological illness present with a wide Box 2: Causes of dysphagia.
range of symptoms from simple oral dysphagia to complex
A. Oral cavity, oropharynx
pharyngeal or oropharyngeal dysphagia. • Painful ulcers
It is to be noted that there is a tremendous increase • Tongue muscle paralysis
in the number of patients who are postsurgery cases of • Mandible fracture
head and neck region, owing to the fact the number of • Surgery in the oral cavity, oropharynx
• Enlarged tonsils
malignancies in head and neck region are on a rise. It
• Tumors in the oral cavity, oropharynx
also denotes the awareness of swallowing rehabilita‑ • Xerostomia
tion among the oncosurgeons. It is very common to get • Postradiation mucositis
a postradiation patient in the oncology group with com‑ • Candidiasis
plaints of dysphagia, the reason for which are dry mouth B. Pharynx
• Foreign body
or mucositis.
• Abscess
Another group is from intensive care units (ICUs) • Laryngeal incompetence
denoting laryngeal incompetence due to prolonged intu‑ • Laryngopharyngeal paralysis
bation or as a part of evaluation of aspiration pneumonia • Cricopharynx dysmotility
which made them get admitted in ICU. • Neck swellings compressing the pharynx
C. Esophagus
Cases of trauma, foreign bodies, and neck swellings • Foreign body
constitute a small group. • Motility disorders
Influence of age on swallowing has been studied by • Tumors involving lumen, wall
Cook IJ et al. and it was found that all stages of swallowing • Tumors, vessels compressing esophagus
are affected. The transit and clearance time are delayed.2 • Motility disorders
• Achalasia cardia

­IMPORTANT? knowledge of the anatomy as well as physiology is of para‑
mount importance in understanding dysphagia.
Report of cervical dysphagia has been found unreliable The methods used in clinical swallow evaluation (CSE)
since 30% of them have primary esophageal problem as starts from a direct administer test to more diagnostic
etiology. Those who localize to chest wall almost always instrumental tests such as flexible endoscopic evaluation
have an esophageal phase disorder.3 of swallowing (FEES) or flexible endoscopic evaluation of
A focus on other systems should be made while taking swallowing with sensory testing (FEESST).4 In most of the
history, such as respiratory system, gastrointestinal sys‑ cases we cannot stop with CSE since the accuracy for find‑
tem, and central nervous system. ing out silent aspiration is nil.5,6
Finally, a prior swallow dysfunction and the treatment The clinician should have an idea of the cognitive and
taken for the same should be noted. language level of the patient before starting examination.
This includes the level of alertness, ability to participate
in examination, over all posture and tone, articulation,
CAUSES voice quality, resonance, and pitch. The quality and rate
Causes are classified into oral, pharyngeal, oropharyngeal, of breathing is assessed before proceeding to the bedside
pharyngoesophageal, and esophageal dysphagia. evaluation. The presence of tracheostomy and the indica‑
Box 2 displays causes of dysphagia. tion for it should be noted. Examination of lower cranial
nerves should be done following that.

CLINICAL ASSESSMENT 1 Clinical Swallow Evaluation (Box 3)

It consists of general examination and motor and sensory We use water for direct administration in small quan‑
physical examination. tity. This is the most common assessment used in stroke
The ability to swallow safely requires the healthy state patients.5 Auscultation over neck while taking water
of upper aerodigestive tract which constitutes the dif­ gives an idea of the severity of obstruction or spasm at
ferent vital functions, viz. breathing and swallowing. So, cricopharyngeal level.
88 Section 2: Clinical Assessment and Office Procedures

Box 3: Evaluation of clinical swallowing. for transfer to do specific investigations such as fluoro­
scopy and flexible endoscopy. It is important to note the
■■ General condition
■■ Level of alertness respiratory rate of the patient while attempting a direct
■■ Ability to participate in examination swallow assessment. A pulse oxymetry is an inevitable tool
■■ Overall posture, tone for assessing the saturation in these patients, because
■■ Articulation aspiration leads to reflex bronchospasm, hypoxia, and
■■ Voice quality
■■ Difficulty managing saliva
■■ Resonance Effect of modification of food such as temperature,
■■ Pitch consistency, and lubrication may be tried.
■■ Rate, quality of breathing
■■ Tracheostomy
Evaluation of oral cavity, oropharynx CLINICAL ASSESSMENT 2
■■ Inspection
• Lips Flexible Endoscopic Evaluation of
■■ Tongue ­Swallowing
■■ Jaw
■■ Teeth With all these findings gathered from the direct swallow
■■ Palate test, the patient is taken for the next level assessment, i.e.
■■ Symmetry, sensation FEES.
■■ Movement, strength, symmetry
■■ Jaw Flexible endoscopic evaluation of swallowing was first
• Tongue described by Susan Langmore et al. (1988).8 This allows
■■ Lips direct visualization of larynx and pharynx before and after
■■ Velum swallow.
■■ Gag reflex (elicited by tongue blade—a normal response
The FEES protocol consists of two level examinations,9
involves tongue protrusion, pharyngeal contraction, and jaw
extension) developed by Langmore. The first level involves assess‑
■■ Involuntary movements ment of anatomy and sensation of laryngopharyngeal
■■ Laryngeal elevation [absence denotes diminished ability to system. The velopharyngeal closure, base of tongue, val‑
open the upper esophageal sphincter (UES)] lecula, epiglottis, vocal cord movement, pyriform fossae,
■■ Cough
pooling of secretions,10 laryngeal elevation and sensation
■■ Efficiency of cough
■■ Repeated swallow of laryngopharynx are noted.
■■ Disordered swallow In the second level, food or liquid is administered
while keeping endoscope above the level of epiglottis
and the act of swallowing is watched directly. Laryngeal
Watching the act of swallowing consists of the posture
elevation, penetration and pooling are assessed. Though
of patient, drooling, laryngeal elevation, and cough. aspiration is difficult to assess, a rough idea is obtained
Cough denotes a number of clues regarding the from the amount of pooling after swallow as well as from
safety of starting on oral feeds. Though annoying to the the ejection of the food material from the trachea by
patient the presence of cough carries a hope of relief to cough.
the ­clinician that the protective mechanism of larynx is
still patent and the chance of pneumonia is less. Timing
of cough is important since it gives information regarding
primary or secondary aspiration. The efficiency of cough is Patient is seated comfortably, the physiological position
also important since protection of lower airway depends for eating. Nasal cavity is decongested with oxymetazoline
largely upon the strength of this protective mechanism to or xylometazoline. Ten percent xylocaine spray is used to
eject the foreign materials. anesthetize the nasal cavity. In children 4% xylocaine drops
Other positive signs of an impaired swallowing func‑ are used. Flexible endoscope is introduced through the
tion include delay in completing the swallow, wet quality nasal cavity and structures are visualized from the velum
or hoarse voice following an act of swallow. to the pharynx. Anatomy and sensation of laryngopharynx
Bedside evaluation of swallowing assessment is are observed followed by administration of food or water.
required in some situations where the patient is not fit Box 4 shows observations made during FEES.
Chapter 8: Clinical Evaluation in a Patient with Dysphagia with Role of FEESST, VFS and TNE 89

Box 4: Observations made during flexible endoscopic eval-

uation of swallowing.
■■ Velum—ability to close against posterior pharyngeal wall
■■ Pharynx—pooling of secretions (Fig. 1)
■■ Laryngeal elevation—white out phase on the video monitor
■■ Larynx—vocal cord mobility
• “Eee-sniff” maneuver
• Breath hold maneuver (patient’s ability to close supra‑
glottis, protect airway)
■■ Degree of pharyngeal muscular contraction
• Pharyngeal squeeze maneuver (PSM)—patient is
instructed to deliver a voluntary, forceful, high‑pitched
“eee” and assess the movement of lateral pharyngeal
walls and narrowing of pyriform sinus. If PSM is abnor‑
mal, there is a high chance of aspiration.11
■■ Laryngopharyngeal sensory testing.
Fig. 1: Rigid laryngoscopy showing pooling of secreations.

Flexible Endoscopic Evaluation of

­Swallowing and Sensory Testing ■■ Absent LAR, absent PSM—ice chips (the cold enhances
sensory information to the patient, poses little harm if
The sensation of larynx is tested with tip of endoscope. aspirated).
Laryngeal adductor response (LAR) is a brainstem‑mediated Also look for:
involuntary reflex arc for airway protection.12-14 Afferent ■■ Premature spillage (loss of bolus in to pharynx before
component is internal branch of superior laryngeal nerve. initiation of swallow)
Recurrent laryngeal nerve forms the efferent arc. It pro‑ ■■ Penetration (passage of material in to laryngeal inlet)
duces a brief and rapid bilateral contraction of thyroary­ ■■ Aspiration (passage of material below the vocal fold).
tenoid muscles. Penetration, aspiration—before swallow (oral, phar‑
yngeal dysfunction), during swallow (neurologic disorder
Pharyngeal Squeeze Maneuver and with sensory deficit), or after swallow (lingual or pharyn‑
Laryngeal Adductor Response geal weakness or outlet obstruction).
Rising tide sign: Postswallow regurgitation out of esoph‑
Taking these responses together helps in prediction of agus into pharynx (esophagopharyngeal reflux). It is seen in
aspiration for different consistencies. Aviv et al. have Zenker’s diverticulum with profound esophageal dysmotility.
demonstrated that absent PSM with intact LAR is likely to
have aspiration with semi-thick consistency. If PSM is intact
with absent LAR aspiration, chance for thin liquids becomes FLUOROSCOPIC EVALUATION
more. So, patients with absent PSM and absent LAR will OF ­SWALLOWING
have aspiration for both thin and thick consistencies.15,16
Fluoroscopic evaluation of swallowing is also called “mod‑
ified barium swallow”. All three stages of swallowing can
PREDICTION OF ASPIRATION be assessed. Even though some studies show that FEES
■■ Pharyngeal squeeze maneuver (–), intact laryngo­ is superior or equal in comparison, fluoroscopy is con‑
pharyngeal sensation—semisolid consistency sidered as the gold standard investigation of swallowing
■■ Pharyngeal squeeze maneuver (+), laryngopharyngeal assessment. In fact they are complementary to each other.
sensation decreased—thin liquids Studies that have compared them show both have equiv‑
■■ Laryngeal adductor response (−), PSM (−)—both thin alent values of sensitivity, specificity, and predictive abili‑
liquids, thick purees. ties.17,18 Exposure to radiation cannot be taken as a serious
So, during tests, the selections of food consistency pre‑ drawback since the amount of exposure is only 8–10 rads
ferred are: as evidenced by some studies.19 Another drawback is the
■■ If LAR (+), absent PSM—water status of the vocal cord cannot be assessed. Apart from
■■ Intact PSM, absent LAR—semisolid these fluoroscope is an excellent tool to assess dysphagia.
90 Section 2: Clinical Assessment and Office Procedures

Box 5: Penetration aspiration scale. Box 6: Davis criteria (predictive scoring system for aspiration
■■ Material does not enter airway 2015).
■■ Remains above folds/ejected from airway (Fig. 2) ■■ Dentition: Normal (0)/abnormal (1)
■■ Remains above folds/not ejected from airway ■■ Mandibular hardware: Nil (0), present (1)
■■ Contacts folds/ejected from airway ■■ Epiglottic abnormality: Nil (0)/shrunken, removed (1)
■■ Contacts folds/not ejected from airway ■■ Pharyngeal wall thickness: If less than one-fourth of C1, C2,
■■ Passes below folds/ejected in to larynx or out of airway C3 vertebrae (0)/if more (1)
■■ Passes below folds/not ejected despite effort (Fig. 3) ■■ Pharyngeal area: Normal (0)/dilated pharynx,—e.g. resec‑
■■ Passes below folds/no spontaneous effort to eject. tion of tongue base (1)
■■ Cervical spine: C3-C6, normal (0)/osteophytes (1)
■■ Cervical spine hardwares: Nil (0)/present (1)
■■ Staples in the neck: Nil (0)/present (1)
■■ Tracheostomy: Nil (0)/present (1)
■■ Maximum score: 9.
Note: If score >2: chance of aspiration.

Fig. 2: Videofluoroscopy showing penetration.

Radiopaque material used is barium which is made

in to three basic consistencies: (1) thick, (2) thin, and
(3) semi-thick.
The basic unit consists of radiographic table, X-ray Fig. 3: Videofluoroscopy revealing aspiration with the trachea
tubes, and monitor. The team consists of the laryngologist, lined with radiopaque dye.
swallowing pathologist, and the radiographer. The patient is
made to sit or stand while observing the act of swallowing.
For pediatric cases we use gastrografin since the amount included in the fluoroscopy. First one is the penetration
of pneumonitis in aspiration is not so severe compared to aspiration scale introduced by Rosenbeck et al. (Box 5).20
barium. All three stages are observed and any postural Second one is a predictive scoring system for aspiration in
adjustments such as chin tuck, head turn are tried to see postsurgery and trauma cases (Box 6).21
whether it facilitates the safety of swallowing (see Fig. 3).
Changing the consistency of bolus is another modifica‑ TRANSNASAL ESOPHAGOSCOPY
tion. The chance to observe the feasibility of planned treat‑
This is an advanced endoscopic evaluation of upper diges‑
ment procedures such as posterior placement, supraglottic
tive tract which is done without giving sedation. Compared
swallow, supersupraglottic swallow, etc. should not be
to esophagogastroscopy, it has got better patient tolerance
missed at any cost.
level and safety. Its role as a screening test helps a lot in
reflux, globus sensation, and chronic cough and provides
PENETRATION ASPIRATION SCALE20 direct view of aerodigestive tract.
Interpretation should be done in a dark room, frame by To perform the test patient is seated upright in a chair,
frame. There are two scoring systems which should be nasal cavity is sprayed with lidocaine, and decongestant
Chapter 8: Clinical Evaluation in a Patient with Dysphagia with Role of FEESST, VFS and TNE 91

is applied. Esophagoscope is with suctioning facility, PEARLS

water instillation, and air insufflation. There is a work‑
■■ A thorough history taking is of great importance in having
ing port for biopsy, forceps introduction for foreign body
an idea about the possible pathophysiology, type of
removal. dysphagia and management options
In patients with esophageal dysphagia a functional ■■ Clinical examination should include examination of oral
esophagoscopy can be done. Described by Belafsky and cavity, neck, throat and respiratory system
Rees (2009), it is called guided observation of swallow‑ ■■ Watching the act of swallowing gives valuable clues
ing in the esophagus (GOOSE). The endoscope is passed ■■ Flexible endoscopic evaluation of swallowing (FEES) and
through the UES after performing a standard FEES. Any Videofluoroscopy are the key investigations
residue in the esophagus after the normal emptying time ■■ Manometry, pH metry and laryngeal sensory testing (LST)
will add to the diagnosis in certain situations.
of 13 seconds is considered as abnormal.21
■■ Transnasal esophagoscopy (TNE) is useful in cases of
­esophageal dysphagia.
High-resolution manometry is used for assessment of REFERENCES
pharyngeal and esophageal motility, UES and lower
1. Belafsky PC, Moudeb DA, Rees CJ, et al. Validity and reli‑
­esophageal sphincter (LES) function. It is a functional ability of the Eating Assessment Tool (EAT-10). Ann Otol
assessment of swallowing. The equipment has got sensors Rhinol Laryngol. 2008;117;919-24.
which helps in distinguishing between pharyngeal weak‑ 2. Cook IJ, Weltman MD, Wallace K, et al. Influence of aging
ness, poor pharyngeal and UES relaxation, incomplete on oral-pharyngeal bolus transit and clearance during
swallowing: scintigraphic study. Am J Physiol. 1994;266
upper esophageal relaxation, esophageal body motility,
(6 Pt 1):G972-7.
and LES function. The candidates for cricopharyngeal 3. Kuhn MA, Belafsky PC. Functional assessment of swal‑
myotomy are selected correctly.3 lowing. In: Johnson J, Rosen CA (Eds). Bailey’s Head and
Neck Surgery: Otolaryngology, 5th edition. Philadelphia:
Lippincott Williams & Wilkins; 2015. pp. 825-37.
pH MONITORING 4. McCullough GH, Martino R. Clinical evaluation of patients
with dysphagia: importance of history taking and physical
Since reflux presents as foreign body sensation and dys‑ exam. In: Shaker R, Easterling C, Belafsky PC, Postma GN
phagia and is one of the most common reason for an (Eds). Manual of Diagnostic and Therapeutic Techniques
outpatient visit evaluation and treatment of laryngo­ for Disorders of Deglutition. New York: Springer-Verlag;
pharyngeal reflux disease (LPRD) has got significant 2013. pp. 11-30.
5. Gordon C, Hewer R, Wade D. Dysphagia in acute stroke. Br
role. Dual probe pH-metry is an important tool in
Med J (Clin Res Ed). 1987;295:411-4.
evalua­tion of LPRD as part of dysphagia evaluation. 6. Linden P, Siebens AA. Dysphagia: predicting laryngeal pen‑
There is a 9-item reflux symptom index (RSI)22,23 con‑ etration. Arch Phys Med Rehabil. 983;64(6):281-4.
sists of questions regarding the symptoms scoring. RSI 7. Ramsey DJ, Smithrd DG, Kalra L. Early assessment of dys‑
of more than 10 is significant since there is high likeli­ phagia and aspiration risk in acute stroke patients. Stroke.
hood of positive results of a dual channel pH probe 8. Lazzara G, Lazarus C, Logemann JA. Impact of ther‑
study. There are multichannel intra­ luminal impe­ mal stimulation on the triggering of swallowing reflex.
dances with pH monitoring (MII-PH) which is the Dysphagia. 1986;1(2):73-7.
preferred investigation for gastroesophageal reflux 9. Langmore S. Endoscopic Evaluation and Treatment of
Swallowing Disorders. New York: Thieme; 2001.
disease (GERD). Even though LPRD may not coexist
10. Murray J, Langmore SE, Ginsberg S, et al. The significance of
with GERD, the MII-PH helps in differentiating between accumulated oropharyngeal secretions and swallowing frequ­
acid reflux from nonacidic reflux. Patients with a nega­ ency in predicting aspiration. Dysphagia. 1996;11(2):99-103.
tive pH test will not benefit from proton pump inhibi­ 11. Bastian RW. The videoendoscopic swallowing study: an
tors. It has been found that pepsin can damage the alternative and partner to the videofluoroscopic swallowing
study. Dysphagia. 1993;8(4):359-67.
laryngeal epithelium at pH 7.24 The reflux finding score
12. Aviv JE, Martin JH, Keen MS, et al. Air pulse quantification
(RFS) is an endoscopic grading scale to mark the severity of supraglottic and pharyngeal sensation: a new technique.
of LPRD.22 RFS of more than 7 is significant. Ann Otol Rhinol Laryngol. 1993;102(10):777-80.
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13. Aviv JE, Martin JH, Kim T, et al. Laryngopharyngeal sensory 18. Rao N, Brady S, Chaudhuri G, et al. Gold-standard? Analysis
discrimination testing and the laryngeal adductor reflex. of videoflouroscopic and fiberoptic endoscopic swallow
Ann Otol Rhinol Laryngol. 1999;108(8):725-30. examinations. J Appl Res. 2003;3:89-96.
14. Aviv JE, Kim T, Sacco RL, et al. FEESST: a new bedside 19. Wambani JS, Korir GK, Tries MA, et al. Patient radiation
endoscopic test of the motor and sensory components of exposure during general fluoroscopy examinations. J Appl
swallowing. Ann Otol Rhinol Laryngol. 1998;107(5 Pt 1): Clin Med Phys. 2014;15(2):4555.
378-87. 20. Rosenbek JC, Robbns JA, Roecker EB, et al. A penetra‑
15. Setzen M, Cohen MA, Perlman PW, et al. The association tion-aspiration scale. Dysphagia. 1996;11(2):93-8.
between laryngopharyngeal sensory deficits, pharyngeal 21. Belafsky PC, Rees CJ. Functional oesophagoscopy: endo‑
motor function, and the prevalence of aspirationwith thin scopic evaluation of the oesophageal phase of deglutition.
liquids. Otolaryngol Head Neck Surg. 2003;128(1):99-102. J Laryngol Otol. 2009;123(9):1031-4.
16. Perlman PW, Cohen MA, Setzen M, et al. The risk of aspi‑ 22. Rosen CA, Lee AS, Osborne J, et al. Development and
ration of pureed food as determined by flexible endoscopic validation of the voice handicap index-10. Laryngoscope.
evaluation of swallowing with sensory testing. Otolaryngol 2004;114(9):1549-56.
Head Neck Surg. 2004;130(1):80-3. 23. Belafsky PC, Postma GN, Koufman JA. Validity and reliability
17. Johns MM, Sataloff RT, Merati AL, et al. Shortfalls of the of the reflux symptom index (RSI). J Voice. 2002;16(2):274-7.
American Academy of Otolaryngology-Head and Neck 24. Johnston N, Wells CW, Samuels TL, et al. Pepsin in non‑
Surgery’s Clinical practice guideline: hoarseness (dyspho‑ acidic refluxate can damage hypopharyngeal epithelial
nia). Otolaryngol Head Neck Surg. 2010;143(2):175-7. cells. Ann Otol Rhinol Laryngol. 2009;118(9):677-85.
Imaging of the Larynx

Sonali H Shah

INTRODUCTION reconstruction of data in coronal, sagittal, and axial planes.

Contrast study is used in many cases, especially for better
Evaluation of the larynx is primarily and easily performed
evaluation of tumors and detection of lymph nodes. Exam­
by endoscopy/stroboscopy, which allows excellent visua­
ination performed during phonatory maneuvers further
lization of the mucosal surface and its abnormalities, per­
aid to study the anterior commissure, aryepiglottic folds,
mitting guided biopsy of suspicious lesions and allowing
and cord movements.1,2
assessment of vocal cord mobility.
A standard CT protocol is performed in supine posi­
Among various imaging modalities computed tomo­
tion, arms by the side of the body, breathing quietly, and
graphy (CT) and magnetic resonance imaging (MRI) play an
refraining from coughing and swallowing.
indispensable complimentary role, as these enable evalua­
Axial scanning is performed from the base of skull to
tion of the deep submucosal structures and spaces, to assess
the carina, with acquisition plane parallel to the hyoid
deeper extent of lesions and visualize the laryngeal skeleton
bone, in order to obtain scans parallel to the vocal cord. A
formed predominantly by the cartilages, which is imperative
512 × 512 matrix is used with a small field of view of 16−20
for complete evaluation. Almost all pathologies affecting
cm and section thickness of 0.75−1 mm, which are used
the larynx including congenital, inflammatory, neoplastic,
for multiplanar and three-dimensional reconstruction. All
and traumatic conditions can be evaluated with imaging, of
images are reviewed in soft tissue and bone windows.
which the most common indication is for neoplasms.
Contrast study with similar protocol is performed after
In many centers, positron emission tomography-com­
administration of nonionic contrast at the rate of 1 mL/kg
puted tomography (PET-CT) also plays a pivotal role for
with hand injection or an automated injector.
staging and follow-up of laryngeal carcinomas.
Additional examination, with “e” phonation is acquired.
The purpose of this chapter is to briefly review cur­
Computed tomography is an X-ray-based technique
rently used imaging protocols, to describe key anatomic
with various structures appearing as different shades of
structures of the larynx relevant to tumor spread, and to
gray, depending on the transmission of the X-rays through
discuss importance of imaging in tumor staging, treatment
them, which is inversely proportionate to the density and
planning, and postoperative evaluation as well as to briefly
glance through some commonly encountered non-neo­ thickness of structures. In simple terms air and fat are dark
plastic laryngeal pathologies. (radiolucent) while cortical bone and metal are at the other
end of the spectrum appearing bright (radiodense), with
metallic densities radiating streaky artifacts. Calcium and
CROSS-SECTION IMAGING acute blood are also radiodense but less than bone. Fluid
“Multi detector CT” is the preferred imaging modality for and rest of the soft tissues are of varying shades of gray.
evaluation of the larynx with known advantages of easy “Magnetic resonance imaging of the larynx” is often
availability, high speed scanning which reduces artifacts used as a specific problem-solving tool, especially in laryn­
caused by breathing and swallowing, allowing excellent geal malignancy for determining cartilage invasion. Dis­
visualization of soft tissue and osseous structures with pos­ advantages of MRI are longer duration of study making it
sibilities of submillimeter slice thickness which ­enables more susceptible to motion artifacts caused by ­breathing,
94 Section 2: Clinical Assessment and Office Procedures

swallowing, and pulsatile flow from adjacent vessels. It is a “Epiglottis” is a fibrocartilage that seldom calcifies
more expensive modality, which requires expertise to read except when damaged. It is a flexible inverted tear drop-
the images. like structure with a broad upper free margin and a fixed
Magnetic resonance imaging study of the larynx is narrow lower portion called as a petiole which attaches
preferably performed on a high-field machine with a ded­ to the thyroid cartilage in the midline by the thyroepiglot­
icated neck coil. Multiplanar noncontrast T1 weighted tic ligament. The hyoepiglottic ligament extends from the
(T1w), T2 weighted (T2w), and T2 fat-saturated/[STIR anterior surface of the epiglottis to the hyoid bone. The sup­
(short tau inversion recovery)] and postcontrast fat-satu­ rahyoid epiglottis provides a lid to the laryngeal lumen and
rated T1 sequences are used, with slice thickness of 4 mm is seen in close proximity to the base of tongue with medial
and interslice gap of 0–1 mm. and lateral glossoepiglottic folds running between the two.
Most fluid and soft tissues appear dark (hypointense) “Thyroid cartilage” is the largest cartilage with double
on T1w images except fat, melanin, and subacute blood laminae which are ventrally fused in the midline. Posteri­
products, which appear bright (hyperintense). Fluid and orly the laminae form the superior and inferior cornua, the
most pathologies appear bright (hyperintense) on T2w superior cornua are connected to the hyoid bone by the
images while air, calcium, and bone appear profoundly thyrohyoid ligament while the inferior cornu articulates
dark on all pulse sequences. with the lateral facets of the cricoid cartilage forming the
The imaging appearance of the cartilages depends on cricothyroid joints.
whether it is ossified or nonossified. The epiglottis and “Cricoid cartilage” is the only complete ring cartilage
vocal process of arytenoids are fibrocartilages which do forming the basic foundation of the larynx. It has a signet
not ossify, hence appearance of soft tissue density on CT ring shape with a narrow anterior arch and broader poste­
images and of intermediate intensity on T1w and T2w rior lamina.
images. Thyroid, cricoid, and rest of the arytenoids are hya­ “Arytenoid cartilages” are pyramidal-shaped paired
line cartilages, which show progressive ossification with structures, perched on the posterior lamina of the cricoid
age. On CT images, ossified cartilages have hyperattenuat­ cartilage forming the cricoarytenoid joints. It has an apex,
ing cortices with low attenuation fat containing medullary which is a part of the supraglottic larynx and attaches to
cavity. On MRI, ossified cartilages have low-signal cortical the vestibular ligament. Rests of the arytenoids are part
margins and fat-filled medullary cavity appearing of high of the glottis, with two projections seen at their base, the
signal on T1w and T2w images. vocal process seen anteriorly and muscular process poste­
Positron emission tomography-computed tomogra­ rolaterally. The vocal ligament seen along the free margin
phy with the glucose analog fluorodeoxyglucose (FDG) of the true vocal cord is attached to the vocal process while
has become an accepted and widely used imaging modal­ the lateral and posterior cricoarytenoid, and oblique
ity for the staging and follow-up of head and neck cancers. arytenoid muscles attach to the muscular process.
It has been used successfully for assessment of tumor The thyroid, cricoid, and arytenoid cartilages are hyaline
aggressiveness, for staging nodal disease in the neck, and cartilages which ossify to varying degrees with age, starting
for detection of recurrent disease.3 Fluorodeoxyglucose from 8 years to 10 years. Fatty marrow develops in these
negative scan excludes recurrence while FDG positive ossified portions, which are more prone for direct tumor
scan needs biopsy for further evaluation. A “silent pro­ invasion. Unfortunately the ossification proceeds in a
tocol” is used, as any activity like tongue and vocal cord variable and asymmetric manner, which makes detection
motility increases the FDG activity and can be read as a of cartilage invasion very challenging.
false positive scan. “Hyoid bone” is a part of the lingual apparatus which
provides a scaffold for the muscles, which suspends the
larynx. It is a U-shaped bone with an anterior body and
two small and large cornua posteriorly.
Larynx is a tubular structure with an outer skeleton and “Quadrangular membrane” anteriorly attaches to the
inner mucosal folds separated by spaces filled with fat and lateral margins of the epiglottis and extends posteriorly to
muscles.4 attach to the arytenoid and corniculate cartilages. The upper
“Outer skeleton” of the larynx is made of cartilages, end supports and forms the aryepiglottic (AE) folds while
membranes, and ligaments. The four principal cartilages its lower margin extends from the base of the epiglottis to
are the epiglottis, thyroid, arytenoids, and cricoid. the apex of the arytenoids forming the false vocal cords.
Chapter 9: Imaging of the Larynx 95

Fig. 2: Anatomy of larynx in axial view.

ventral surface of epiglottis, extending cranially from the

thyrohyoid ligament to the thyroepiglottic ligament cau­
Fig. 1: Anatomy of larynx in frontal view. dally.
Paraglottic spaces (PGS): These are paired fat-filled lat­
eral spaces deep to the mucosa of the true and false local
cords, which are bound laterally by thyroid cartilage and
thyrohyoid membrane and medially by the quadrangular
membrane in the upper larynx and conus elasticus in the
lower half. At the level of the false cord it is filled by fat and
at the level of the true cord by the thyroarytenoid muscle.
The PGS are contiguous superiorly with the PES and ante­
rolaterally with the extralaryngeal soft tissue as they have
no major fascial barrier.
Laryngeal ventricles are air-filled spaces between the
true and false cords which extend laterally into the PGS
and are best seen on the coronal images. At the level of the
false cords a small mucosa lined recess projects superiorly
from the lateral ventricle which is called as a laryngeal sac­
Fig. 3: Anatomy of larynx in coronal view. cule/appendix, which if dilated forms a laryngocele.
Laryngeal compartments: Two imaginary horizontal
lines divide the endolarynx. The first line extends through
“Conus elasticus” is an inverted funnel-shaped mem­ the apex of the laryngeal ventricle and the second line is
brane extending from the vocal ligament to the upper mar­ 1 cm caudal and parallel to it.
gin of the cricoid cartilage. The supraglottis larynx is above the first line, consist­
“Thyrohyoid membrane” attaches the hyoid bone to ing of the epiglottis, AE folds, false cord, and upper aryte­
the thyroid cartilage while the “cricothyroid membrane” noid cartilages.
attaches the cricoid cartilage to the thyroid cartilage (Figs. The glottis is between the two lines including the true
1 to 3). vocal cord and anterior and posterior commissures.
The subglottis is between the second line and the lower
LARYNGEAL SPACES margin of the cricoid cartilages.
The laryngeal spaces are seen between the laryngeal
mucosa and the outer skeleton.
Important Radioanatomy
Pre-epiglottic space (PES): It is fat-filled “C”-shaped True vocal cords are predominantly composed of the thy­
space rich in lymphatics seen between the hyoid bone and roarytenoid muscles and a medial fibrous band called as
96 Section 2: Clinical Assessment and Office Procedures

a vocal ligament. They extend from the vocal process of malignancy into the cartilage. “Posterior commissure” is
the arytenoids to the thyroid lamina anteriorly, below the a mucosal surface in the interarytenoid region, anterior
insertion of the petiole. to the cricoid cartilage. Thickness of both the anterior and
“False vocal cords” run parallel and superior to the posterior commissures should not be more than 1 mm.
true vocal cord with the paraglottic fat seen submucosally. “Pyriform fossae” are mucosal lined recesses of the
On T1w MRI images, the muscular true cords, appear hypopharynx seen on either side, lateral to the AE folds
isointense to muscles and are easily differentiated from and medial to the thyroid cartilage.
the high signal intensity of the fat within the false cords. “Valleculae” are part of the oropharynx, which are
“Anterior commissure” is where the true vocal cords formed by the median and two lateral glossoepiglottic
meet anteriorly and insert into the thyroid cartilage via folds, seen running between the base of tongue and the
the Broyle’s ligament. There is no perichondrium at this free margin of the epiglottis (Figs. 4A to G, 5A and B, and
point, hence forming a potential site for direct spread of 6A to D).


Figs. 4A to D: (A) Normal anatomy of larynx. Craniocaudal axial postcontrast CT sections: supraglottic region showing tip of epiglottis
(thick arrow). (B) Normal anatomy of larynx. Craniocaudal axial postcontrast CT sections: supraglottic region shows paired valleculae
(thin arrows) and epiglottis (thick arrow). (C) Normal anatomy of larynx. Craniocaudal axial postcontrast CT sections: supraglottic region
shows epiglottis (thick arrow), preepiglottic fat space (star), and hyoid bone (block arrow). (D) Normal anatomy of larynx. Craniocaudal
axial postcontrast CT sections: supraglottic region showing the aryepiglottic folds (short block arrows), pyriform fossae (5 point stars),
and paraglottic fat space (thin arrows), and thyroid notch (4 point star).
Chapter 9: Imaging of the Larynx 97


Figs. 4E to G: (E) Normal anatomy of larynx. Craniocaudal axial

postcontrast CT sections: supraglottic region at level of false cords
(arrows) under which fat containing paraglottic spaces are seen
(elbow arrows). (F) Normal anatomy of larynx. Craniocaudal axial
postcontrast CT sections: glottic region showing the true vocal
cords (block arrows), anterior commissure (curved arrow), posterior
commissure (short arrow) and cricoarytenoid joints (long arrows).
(G) Normal anatomy of larynx. Craniocaudal axial postcontrast CT
sections of the larynx: subglottic region showing the cricoid ring
G (arrows).

Figs. 5A and B: (A) Coronal reconstructed CT image showing the epiglottis (thin arrow), false cord (elbow arrow), laryngeal ventricle
(thick arrow), true cord (block arrow) and paraglottic space (stars). (B) Sagittal reconstructed CT image showing the free margin of epi-
glottis (thin arrow), preepiglottic space containing fat (long block arrow), and hyoid bone (block arrow).
98 Section 2: Clinical Assessment and Office Procedures


Figs. 6A to D: (A) T1-weighted sagittal image showing free margin of epiglottis (thin arrow) and bright fat in preepiglottic space (long
block arrow). (B) T1-weighted axial image at level of false cord, revealing hyperintense fat in paraglottic spaces bilaterally (block arrows)
and the thyroid laminae (long arrows). (C) T1-weighted axial image at level of true cord, revealing the thyroarytenoid muscle forming
the true cord (block arrows), anterior commissure (4 point star) and cricoarytenoid joint (thin arrows). (D) T1-weighted axial image at
level of subglottic region, revealing the unossified cricoid (block arrows) and thyroid cartilages (arrows) and ventrally the cricothyroid
membrane (elbow arrow).

tracts. Integration of cross-section imaging and endoscopic

LARYNGEAL CARCINOMA findings significantly improved the accuracy of T-staging,
Almost 90% of laryngeal neoplasms are squamous cell which is as high as 80% as reported by Zbaren et al.8,9
carcinomas,5 which are strongly related to alcohol and The TNM (tumor, lymph node, and metastasis) clas­
smoking.6 Clinical examination followed by endoscopy sification laid down by American Joint Commission on
is the first step in T-staging of laryngeal carcinomas. Cancer (AJCC) is universally accepted for staging laryn­
Computed tomography and MRI studies are performed geal carcinoma (Tables 1 to 3).10 This classification incor­
to assess the submucosal extent, deeper margins of the porates all information available prior to the treatment
tumor, invasion of the adjacent structures, nodal disease, including clinical examination, endoscopic finding, endo­
synchronous tumors, and metastatic spread.7 Patients scopic biopsy report, and cross-section imaging. However,
with laryngeal carcinoma have a high-risk for synchro­ no recommendations are made regarding the preference
nous malignancy arising from the lung and aerodigestive of one cross-section imaging over the other.
Chapter 9: Imaging of the Larynx 99

Table 1: T-staging of laryngeal cancers (according to AJCC).

T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility.
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis
(e.g. mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, preepiglottic space,
paraglottic space, and/or inner cortex of thyroid cartilage.
T4a Moderately advanced local disease.
Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of neck
including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.
T1a Tumor limited to one vocal cord.
T1b Tumor involves both vocal cords.
T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility.
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid
T4a Moderately advanced local disease.
Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g. trachea, soft
tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
T1 Tumor limited to the subglottis.
T2 Tumor extends to vocal cord(s) with normal or impaired mobility.
T3 Tumor limited to larynx with vocal cord fixation.
T4a Moderately advanced local disease.
Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of neck includ­
ing deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
(AJCC: American Joint Committee on Cancer).

Table 2: Regional lymph nodes (N).

NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension.
N2 Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension.
Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension.
Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension.
N2a Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension.
N2b Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension.
N2c Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension.
N3 Metastasis in a lymph node, >6 cm in greatest dimension.
100 Section 2: Clinical Assessment and Office Procedures

Table 3: Distant metastasis (M). False cord carcinomas have a strong predilection for
M0 No distant metastasis. submucosal spread into the PGS due close anatomic prox­
M1 Distant metastasis. imity, with larger lesions revealing destruction of the thy­
roid cartilage as well as transglottic extension into the glot­
Radiological criteria used for tumor involvement are tis and subglottis. Both CT and MRI have high sensitivity
asymmetric soft tissue thickening, bulky mass, contrast of about 95% to detect paraglottic spread but specificity,
enhancement, obliteration of fat planes and spaces, or a ranges between 50% and 75% as peritumoral inflamma­
combination of these.9,11 tion mimics tumor infiltration resulting in false positive
Supraglottic Carcinoma
Approximately 30% of all laryngeal carcinomas are in Glottic Carcinoma
the supraglottis. They present at an advanced stage with They represent about 65% of laryngeal cancers, which
symptoms of hoarseness due to vocal cord involvement, present early with hoarseness of voice. The glottis has
which does not occur until late. As the supraglottis is rich
poor lymphatic network hence, metastatic nodal disease is
in lymphatic network, nodal disease is commonly seen.
uncommon. A true vocal cord mass frequently arises from
The overall 5-year survival rate is 75%.12
the anterior half which can spread into the anterior com­
“Epiglottic carcinomas” are anterior midline carci­
missure, from here to the contralateral cord as well as ante­
nomas, which spreads into the PES and from here to the
riorly into the thyroid cartilage via the Broyle’s ligament.
tongue base and laterally to the PGS. Tumors arising from
Posteriorly it invades the arytenoids, cricoid cartilage,
the petiole can spread to the PES, anterior commissure,
glottis, and subglottis. The primary sign of invasion of PES cricoarytenoid joint, or the posterior commissure, lead­
on imaging is replacement of fat by abnormal enhancing ing to a fixed cord.12,14 Superiorly it extends into the PGS,
soft tissue (Figs. 7A and B). The sensitivity of CT and MRI to inferiorly into the subglottic space, and laterally into the
detect this invasion is 100% and specificities are 93% and extralaryngeal soft tissue through the cricothyroid mem­
84–90%, respectively.8,13 brane.
“Aryepiglottic fold carcinomas” are exophytic or infil­ Anterior commissural disease is seen on CT and MRI
trative masses that spread into the PGS laterally with as soft tissue thickening of more than 1–2 mm (Figs. 9A
further spread anteriorly into the PES and posteriorly into and B) with the accuracy of CT predicting involvement
the pyriform fossa (Figs. 8A and B). reaching up to 75%.15

Figs. 7A and B: Contrast CT axial (A) and sagittal (B) images reveal a large epiglottic mass involving the preepiglottic space (arrows),
the vallecula (curved arrow) and base of tongue (block arrow).
Chapter 9: Imaging of the Larynx 101

Figs. 8A and B: Contrast CT axial (A) and coronal (B) images reveal a right supraglottic squamous cell carcinomas involving ipsilateral
aryepiglottic fold (block arrows) with invasion of paraglottic space (short arrow), obliteration of pyriform sinus, and metastatic adeno­
pathy (long arrow).

Figs. 9A and B: Contrast CT axial (A) and coronal (B) images of right glottic squamous cell carcinomas revealing mild asymmetric
thickening of the true cord (long arrow) extending to involve the anterior commissure (block arrow).

Subglottic Carcinoma spread anteriorly through the cricothyroid membrane into

These are the least common of the laryngeal carcinomas, the thyroid gland, posteriorly into the cricoid cartilage and
with incidence of about 5%. They have poor prognosis, as posterior commissure, superiorly into the glottis, and infe­
they remain clinically silent and present only by the time riorly into the tracheal lumen. Lymph node metastases
they are large and invasive, with a 5-year survival rate of into the pre- and paratracheal lymph nodes are common.
40%.12 Subglottic larynx has almost imperceptible soft Detection of an enlarged Delphian node, anterior to the
tissue between the airway and cricoid cartilage, hence cricothyroid membrane suggests invasion/involvement of
whenever any soft tissue thickening is noted in this region, anterior subglottis or anterior commissure and indicates
cancer or subglottic spread is diagnosed. These cancers poor prognosis.
102 Section 2: Clinical Assessment and Office Procedures


Figs. 10A to F: Right transglottic squamous cell carcinomas (white arrows) involving the (A) Right valleculae; (B) Epiglottis and right
aryepiglottic fold; (C) Right paraglottic space and pyriform sinus; (D) Right false cord; (E) Right true cord and anterior commissure with
exolaryngeal spread (4-point star); and (F) Subglottic extension.

Figs. 11A and B: Right transglottic squamous cell carcinomas (white arrows). (A) Coronal reconstruction revealing subglottic and
exolaryngeal extension (block arrow); (B) Sagittal reconstruction.
Chapter 9: Imaging of the Larynx 103


Figs. 12A to D: Magnetic resonance imaging reveals a right transglottic squamous cell carcinomas (white arrows) (A) T1-weighted
axial; and (B) STIR axial reveal invasion of the right paraglottic space; (C) STIR coronal image reveals exolaryngeal spread through the
thyrohyoid membrane and cricothyroid space; (D) STIR sagittal.

Transglottic Carcinoma Tumor “T” staging: Delineation of the exact tumor size,
tumor extent and detection of other associated findings
When the origin of the mass is unclear and it involves the have a great impact on treatment planning which includes
glottis and supraglottis larynx, with or without subglottic the type of surgery, radiotherapy and chemotherapy or
extension, it is called transglottic tumor.2,3 combination of these.
Coronal images are helpful in complete assessment There are important parameters for “T” staging that
of tumor, which easily extends into the PGS and are often influence the management of patients, which are clinical
accompanied by metastatic lymphadenopathy3 (Figs. 10 blind spots, like presence of tumor in submucosal space,
to 12). spread across the commissure, subglottic extension, con­
tiguous cartilage invasion, and exolaryngeal spread. These
VITAL IMAGING FINDINGS are however easily detected on the CT and MRI imaging.9

There are vital imaging parameters used for prognosis of the

disease process, which includes detection of cartilage inva­
sion, tumor volume, nodal disease, distant metastases, and Cartilage invasion depends on tumor size and location
synchronus disease. and proximity to cartilage with the ossified regions at
104 Section 2: Clinical Assessment and Office Procedures

Figs. 13A and B: Contrast axial CT images, soft tissue window (A) and bone window (B) reveal an advanced transglottic mass (white
arrows) with erosion of cricoid cartilage (block arrows).

higher risk of invasion due to vessel penetration. Tumors criteria for invasion but lower sensitivity (Figs. 13A and B).8
confined to the supraglottic region rarely reveal cartilage While sclerosis has a high sensitivity (83%) but lower speci­
invasion,16 which is more problematic in glottic, subglot­ ficity, varying from cartilage to cartilage, thyroid (40%),
tic, and hypopharyngeal tumors. Epiglottic involvement cricoid (76%), and arytenoid (79%).8,17,19
has no significant impact on treatment as it is routinely
removed in supraglottic laryngectomy, similarly partial Magnetic Resonance Imaging
resection can be performed even if vocal process of aryt­
Magnetic resonance imaging is used as a problem-solving
enoids are minimally involved. Invasion of thyroid, cri­
tool and in some institutes as a primary modality for imag­
coid, and both arytenoid cartilages are however impor­
ing. The negative predictive value for cartilage invasion is
tant for prognosis, as it alters the staging and in most
as high as 94–96%.8,19
centers, the therapeutic approach precluding possibility
A hypointense signal on T1w images against the bright
of c­ onservative surgery, with a mandatory requirement of
signal of the medullary fat with corresponding bright sig­
a total laryngectomy. Poor outcome of radiotherapy is also
nal on fat-saturated T2/STIR images and enhancement on
seen with predisposition to complications like perichon­
the postcontrast study are accepted criteria for cartilage
dritis and cartilage necrosis.
invasion. However, peritumoral edema can have similar
imaging appearance, hence to increase the specificity of
Computed Tomography cartilage invasion, Becker et al.17,19 suggested that the T2w
Computed tomography criteria for cartilage invasion and gadolinium enhanced T1w images of the suspected
include sclerosis, erosion, lysis, and exolaryngeal soft cartilage should be compared with the mass, if it is of sim­
tissue.17,18 The sensitivity and specificity of CT for detection ilar signal then it is likely to be invaded and if not then
of cartilage invasion depends on degree of ossification and peritumoral edema is possible (Figs. 14A to C).
varies from cartilage to cartilage. As laryngeal cartilages
ossify in an irregular and asymmetric fashion, attenuation NODAL DISEASE (N-STAGING)
of tumor and unossified cartilage appears similar hence
minimal invasion can be missed. Similarly though detec­ A minimum axial diameter more than 10 mm, round or
tion of cartilage sclerosis is a sensitive sign, it can be seen as spherical shape, a necrotic node of any size and a node
a reactive bone change or preceding tumor invasion and not with indistinct margins (suggesting extranodal disease
necessarily due to invasion, hence posing a great diagnostic spread) are the criteria used to diagnose malignant nodes
challenge for accurate detection of cartilage involvement. on CT and MRI images (Figs. 15A and B).20 The sensitivity
Erosion, lysis, and exolaryngeal spread has high-specificity and specificity of CT to detect nodal disease using these
Chapter 9: Imaging of the Larynx 105

Figs. 14A to C: Magnetic resonance imaging reveals an advanced transglottic squamous cell carcinomas (white arrows) with cartilage
destruction (block arrows) and exolaryngeal spread (black arrows): (A) T2 axial; (B) STIR axial; and (C) Postcontrast axial images. Note
the mass and involved cartilage have similar signal intensity and enhancement.

Figs. 15A and B: Contrast CT axial (A) and (B) images reveal a right supraglottic squamous cell carcinomas (arrow) with B/L metastatic
cervical lymph nodes (block arrows).

criteria are 90% and 75%, respectively. When unilateral carcinoma will develop distant metastasis within 2 years
nodes are involved, there is 50% reduction in the long- of diagnosis.7
term survival of the patient, while when bilateral nodes are A chest radiograph would usually suffice in early can­
involved there is up to 75% reduction.9 cer, while PET-CT/CT chest is recommended for advanced
Distant metastases are usually manifested late in the
course of the disease, upstaging from M0 to M1, with lungs Posttreatment imaging is advised to look for tumor
and bones seen as common sites (Fig. 16). About 15% of response and to detect residual or recurrent disease, espe­
patients with supraglottic and 3% of patients with glottic cially in the first 2–3 years.
106 Section 2: Clinical Assessment and Office Procedures


They account for less than 5% of tumors, ranging from
benign to malignant neoplasms, which are mostly sub­
mucosal, appearing as a bulge on laryngoscopic exam­
ination. Computed tomography is helpful in detecting
the extent, possibly characterizing it depending on the
enhancement or ossification/calcification pattern and
most importantly guides the scopist regarding optimal
site for biopsy.

Fig. 16: Contrast CT axial image (bone window) reveals a meta- Cartilaginous and osteogenic tumors of larynx include
static osteolytic lesion (block arrow) involving the left frontal bone, chondromas, chondrosarcoma, and osteosarcoma. Chon­
in a known case of a right supraglottic squamous cell carcinomas drosarcomas are low-grade malignant neoplasms present­
with B/L metastatic cervical lymph nodes (same case as Fig. 15).
ing in the 6th/7th decade as an expansile enhancing mass
with fine, punctate, stippled to coarse popcorn-like cal­
Postradiation there is extensive edema, diffuse thicken­ cification. About 75% of the laryngeal chondrosarcomas
ing, and enhancement of the laryngeal structures, which involve the cricoid cartilage.
may confound the imaging interpretation. These changes
can persist for at least 12 months or indefinitely and should
not be misinterpreted, as recurrence, however asymmetric
signal or focal masses should alert the imaging specialist ­SYSTEM
for recurrence. Chondronecrosis is indicated when there is Lymphoma
fragmentation, sclerosis, and lysis of the cartilages.
Positron emission tomography-computed tomogra­ These are rare tumors but second most common hemato­
phy has superior diagnostic accuracy in detecting tumor logical tumor of the larynx after plasmacytoma. Primary
recurrence and it also helps to facilitate the difference lymphoma are mainly non-Hodgkin lymphoma, most are
between radiotherapy changes and recurrence.22 diffuse large B cell lymphoma (DLBCL) or mucosa-associ­
Positron emission tomography-computed tomogra­ ated lymphoid tissue (MALT) lymphoma.24
phy scores higher than routine CT/MRI studies especially It usually involves the supraglottis as it contains fol­
in post chemoradiotherapy cases. A decrease in the FDG licular lymphoid tissue in lamina propria and ventricles.
activity in the earlier phase of treatment is associated with On imaging, they appear as a large homogenous mass
greater tumor response, survival, and local control.23 Suc­ without necrosis, not very different from squamous cell
cessful radiotherapy is considered when tumor volume is carcinoma, but can be differentiated when on endos­
reduced within 4 months of treatment, and treatment fail­ copy a large submucosal mass is seen without ulceration
ure is suggested if more than 50% of tumor is visible after (Figs. 17A to C). Differentiation is essential as lymphoma
this period.9,21 is primarily treated by chemoradiotherapy rather than
Surgery for laryngeal carcinoma results in significant surgery.
anatomic distortion with redundant mucosa, distorted
airways, obliterated paralaryngeal fat planes, and devel­
opment of postoperative granulomas, which makes detec­
tion of recurrence difficult on endoscopy and CT study. In Extramedullary plasmacytoma is rare and laryngeal
a postoperative CT study, soft tissue or nodularity of more involvement is seen in about 10% of cases. Computed
than 1 cm seen at the operative site especially at the pexy tomography reveals a homogenous mass, very similar to
site should suggest recurrence. lymphoma.
Chapter 9: Imaging of the Larynx 107


Figs. 17A to C: (A) Laryngoscopy image revealing a right supra-

glottic mass (white arrow); (B) Postcontrast axial; and (C) Coronal
reconstruction in the same patient show a right supraglottic mass
without areas of necrosis. Histopathological examination was
C suggestive of non-Hodgkin’s lymphoma.

TUMORS OF MINOR SALIVARY GLANDS and paraganglioma appear as well-circumscribed soft

tissue masses that exhibits intense contrast enhancement
Adenocarcinoma, adenoid cystic carcinoma, and mucoep­ (Figs. 18A and B). Phleboliths are pathognomonic for
idermoid carcinoma arise from the minor salivary glands. hemangiomas. On MRI, laryngeal hemangiomas, displays
Adenoid cystic carcinoma is typically found in the subglot­ a very high-signal intensity on T2w sequences and intense
tis of patients without a history of smoking. These tumors but often inhomogeneous enhancement on T1w images
can be located beneath a completely intact mucosa and after administration of gadolinium chelates. Larger paragan­
displays a characteristic pathway of perineural spread glioma typically reveals multiple curvilinear signal voids on
along the recurrent laryngeal nerve. None of these unu­ both T1w and T2w images. The conspicuity of these signal-
sual types of carcinoma has any imaging characteristics void areas is directly proportionate to the tumor size.
that allow its distinction from squamous cell carcinoma
and deep, aggressive biopsy is mandatory to clarify the
Lipoma of the larynx and hypopharynx are rare. The radio­
logical diagnosis is straightforward: the typical CT features
VASOFORMATIVE TUMORS are those of a homogeneous, nonenhancing lesion with fat-
Strongly vascularized laryngeal tumors include heman­ like attenuation values from −65 Hounsfield units to −125
gioma and paraganglioma. On CT, both hemangioma Hounsfield units. On MRI, lipoma has the same signal
108 Section 2: Clinical Assessment and Office Procedures

Figs. 18A and B: Contrast CT study axial sections (A) arterial and (B) venous phases reveals an enhancing left supraglottic heman-
gioma (white arrows).

Figs. 19A and B: Postcontrast axial CT sections of the chest (different patients) showing causes of recurrent laryngeal nerve palsy.
(A) Reveals enlarged mediastinal nodes and (B) Enlarged left atrium due mitral valve stenosis in a case of Ortner’s syndrome.

intensity as the s­ ubcutaneous fat and reveals no significant

enhancement after administration of intravenous contrast
material. Vocal cord paralysis occurs due to dysfunction of recurrent
laryngeal nerve (Figs. 19A and B). They present with hoarse­
METASTASES ness of voice, but can be asymptomatic in 40% of the cases.
The most common mechanism of metastatic spread is Any offending lesion along the course of the vagal and recur­
through the systemic circulation. The primary sources of rent laryngeal nerves between the medulla oblongata and the
metastatic tumor (in order of decreasing frequency) are skin aortic arch can cause vocal cord palsy. Usually pathologies of
(melanoma), kidney, breast, lung, prostate gland, colon, the brainstem and the skull base, would present with mul­
stomach, and ovary.25 Radiological features are nonspe­ tiple cranial nerve palsies, while lesions along the extracra­
cific. In case of renal cell carcinoma metastases, the lesion is nial course of the vagal and recurrent laryngeal nerve would
hypervascular and will reveal intense arterial enhancement. present with unilateral or bilateral vocal cord palsy.
Chapter 9: Imaging of the Larynx 109


Figs. 20A to C: Postcontrast axial CT sections of the larynx (A) re-

veals medial positioning of left aryepiglottic fold, medial dislocation
of arytenoid cartilage (block arrow) with prominent pyriform fossa
(star); (B) Shows a dilated ipsilateral laryngeal ventricle. Coronal
reconstruction CT image of the larynx in phonation; and (C) reveals
a dilated laryngeal ventricle, pointed true cord, and loss of left sub-
C glottic arch (arrow).

A CT study from the skull base to the aortic arch is Findings of Vocal Cord Palsy26
mandatory with or without contrast with quiet breathing,
plane parallel to the vocal cord, and “E” phonation. Meti­ Primary Signs (Figs. 20A to C)
culous attention is paid along the entire course of the
■■ Medial deviation and thickening of the aryepiglottic
Causes of Vocal Cord Palsy ■■ Prominence of the ipsilateral laryngeal ventricle
■■ Dilatation of the ipsilateral pyriform sinus.
■■ Infective/Inflammatory neuritis
■■ Surgical/iatrogenic
■■ Neoplastic: Infective/neoplastic lymph nodes, neuro­ Secondary Signs
genic tumors like schwannoma, paraganglioma, and ■■ Pointed true vocal cord in coronal images
malignancy such as esophageal and bronchogenic
■■ Paramedian location of the true vocal cord with pseu­
carcinoma, lymphoma, and thyroid tumors.
■■ Vascular: Aortic aneurysm, pulmonary arterial enlarge­
■■ Anteromedial dislocation of the arytenoid
ment, enlarged left atrium, and severe mitral stenosis
with left atrial enlargement. ■■ On “E” phonation the paralyzed vocal cord remains in
■■ Traumatic. adducted position.
110 Section 2: Clinical Assessment and Office Procedures

LARYNGOCELE space, contained laterally by the thyrohyoid membrane/

thyroid cartilage (Fig. 21). When they cross the thyrohyoid
Dilatation of the laryngeal appendix/saccule is called membrane and extend laterally into the anterior soft tissue
laryngocele. structures of the neck, it is called mixed laryngocele. The
A laryngeal appendix is a rarely discussed small ver­
term external laryngocele is used when the internal com­
tically oriented cul-de-sac, extending cranially from the
ponent of the mixed laryngocele collapses.27
anterosuperior portion of the laryngeal ventricle within
The fluid-filled laryngocele is called saccular cyst
the supraglottic fat.
which can get superadded infection called laryngopyocele
Obstruction of the appendix or repetitive increase in
which may lead to rapid airway compression and death
the intralaryngeal pressure (wind/brass instrumentalist)
(Figs. 22A and B).
causes dilatation of this space forming an air or fluid-filled
These patients are either asymptomatic or may present
with hoarseness of voice, stridor, cough, pain, snoring, or a
An internal laryngocele is a blind-ended tubular air-
visible palpable mass in the neck.
filled structure extending cranially into the paraglottic fat
When a laryngocele is diagnosed clinically/radiolog­
ically, a small associated lesion obstructing the appen­
diceal orifice must be looked for like a carcinoma or benign
lesions such as a rhabdomyoma, granular cell tumor, and
laryngeal prosthesis.27
On laryngoscopy, a laryngocele presents as a submu­
cosal supraglottic mass.

Trauma may be blunt or penetrating and often iatrogenic,
causing mucosal tears, submucosal hematoma, fractures
of the cartilage, and joint dislocation. Thyroid fracture can
be vertical, horizontal, or comminuted (Figs. 23A and B).
The cricoid fractures are usually bilateral. Dislocation of
arytenoid cartilage occurs most commonly during intuba­
Fig. 21: An air-filled RT sided laryngocele (white arrow) seen on coro­ tion. It gets displaced anteriorly with the vocal cord located
nal reconstructed CT image, in contiguity with laryngeal ventricle. in a paramedian position, which mimics a paralyzed vocal

Figs. 22A and B: A fluid-filled left sided pyolaryngocele/saccular cyst (white arrows) extending beyond the thyrohyoid membrane as
seen on the axial (A) and coronal reconstructed (B) Computed tomography images.
Chapter 9: Imaging of the Larynx 111

Figs. 23A and B: CT axial images (bone window) (A) and (B) reveals fractures of thyroid and cricoid cartilages causing no significant
laryngeal compromise.

Figs. 24A and B: Postcontrast axial CT sections of the larynx (A) and (B) reveals diffuse enlargement and inhomogeneous enhance-
ment of the bilateral aryepiglottic folds and vocal cords. Biopsy of the lesion was suggestive of tuberculosis.

cord. Dislocation of the cricothyroid joint can occur rarely True vocal cord, arytenoid cartilages, and interaryt­
and is usually seen in severe trauma. enoid space are commonly involved with CT revealing
Long­-term sequelae of trauma, includes cartilage bilateral diffuse laryngeal soft tissue lesions without dis­
deformation, pseudoarthrosis, chondroid metaplasia, crico­ tortion of the architecture or destruction of the cartilage
ary­tenoid ankylosis, subglottic stenosis, and posttraumatic (Figs. 24A and B).
granuloma. The radiological findings of laryngeal tuberculosis
depend on the stage and lesion extension. In the infil­
trative stage, focal thickening is seen. In the ulcerative
stage, the ulceration is not deep and rarely reaches
Epiglottitis and croup are diagnosed clinically, not requir­ the PGS and the cartilage. Sometimes perichondritis
ing any form of imaging. Among the granulomatous dis­ is noted (epiglottis and arytenoids) with calcifications
ease of larynx, tuberculosis is still the most common which and involvement of the paralaryngeal fat spaces seen
may result either due to pooling of secretions in the poste­ uncommonly. The last stage of the disease is often char­
rior larynx or due to hematogenous spread. acterized by sclerosis.28,29
112 Section 2: Clinical Assessment and Office Procedures

Figs. 25A and B: Coronal (A) and sagittal (B) CT reconstruction images of the larynx reveal a segment of subglottic stenosis and a
tracheostomy tube in situ.

LARYNGEAL STENOSIS 8. Zbaren P, Becker M, Läng H. Pretherapeutic staging of

laryngeal carcinoma: clinical findings, CT and MRI with
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Committee on Cancer: larynx. In: Greene FL (Ed). AJCC
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and reconstructed images of the multislice CT study (Figs. 1998;19:492-503.
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Neuroradiol. 2010;31(7):1261-5. features. Indian J Radiol Imaging. 2010;20(1):11-2.
Injection Laryngoplasty

Nupur Kapoor Nerurkar, Farha Naaz Kazi

INTRODUCTION method was soon abandoned due to problems such as

paraffinomas and embolism.
Injection laryngoplasty (IL) has re-emerged as a valuable In 1955, the IL procedure was revived by Arnold who
treatment modality for a spectrum of voice disorders. used autologous cartilage for medialization.3 Teflon as an
The recent advances in the variety of injection materials, IL material gained wide popularity after Lewy described its
technical advancement, avoidance of both general anes- use in the year 1963,4 until the mid-1990s. However, this too
thesia and admission in the hospital bringing down had to take a backseat due to complications such as Teflon
over­all cost of the procedure, have all contributed toward granulomas (granulomatous reaction occurring around
resurgence of this technique. the injected Teflon) and migration. The treatment of these
Teflon granulomas involved their surgical excision either
PRINCIPLE OF INJECTION endoscopically or via a laryngofissure approach. Netterville
­LARYNGOPLASTY JL et al. described complete removal of Teflon granuloma
by a lateral laryngotomy under local anesthesia.5 With both
Injection laryngoplasty is a technique of injecting a mate- these surgical approaches, there was a risk of vocal fold
rial into the paraglottic space in order to medialize the scarring and consequently worsening of the voice.
vocal fold. The ultimate goal of treatment is to bring the Ford introduced the concept of injecting bovine col-
edge of the nonfunctioning vocal fold closer to the midline lagen for medialization of the vocal folds in 1986.6 How-
to facilitate glottal closure during phonation and swallow- ever, this occasionally led to severe allergic reactions and
ing by allowing the functioning vocal fold to approximate thus lost favor. Human derived lyophilized collagen slowly
to the nonfunctioning side more easily.1 Typically, IL is an gained popularity in the 1990s due to an absence of hyper-
office procedure though it may also be performed under sensitivity reactions with its use.
general anesthesia. The technique of using autologous fat for vocal fold
Injection laryngoplasty offers anterior glottic approxi­ augmentation was first reported by Mikaelian in 1991.7
mation for small to medium sized defects (up to 3 mm) Autologous fascia was introduced by Rihkanen in 1998
and has a potential advantage of straightening small with the advantage of low metabolic requirements, more
irregularities in the free edge of the vocal fold depending stability and being less prone to resorption compared to
on the material used.1 autologous fat or collagen.8
Calcium hydroxylapatite has been available commer-
cially since 2003 as Radiesse Voice (Bioform Medical Inc.,
HISTORICAL BACKGROUND San Mateo, CA). Pioneering studies conducted by Belafsky
First recorded experience with IL dates back to 1911 when and Postma in 2003–2004 have proved the efficacy of
Wilhelm Bruening used paraffin to medialize a paralyzed calcium hydroxylapatite as a promising injectable mate-
vocal fold. He described using paraffin, as a transoral pro- rial for injection laryngoplasty.9 However, injection of
cedure, in an awake patient.2 To perform IL, Bruening this material in the subepithelial plane will result in
designed a syringe which enabled him to inject paraffin inflammation and stiffness, some of which is likely to be
through a long 19-gauge needle into the vocal fold. This permanent.10
Chapter 10: Injection Laryngoplasty 115

Carboxymethylcellulose, sold as Radiesse Voice Gel, is ■■ Presbyphonia (voice lift): “Voice lift surgery” is the
the carrier substance used in the longer lasting Radiesse term coined for IL in presbyphonic patients, in whom
Voice injectable. This has been utilized extensively for the procedure is performed for their spindle shaped
temporary vocal fold paralysis and for trial vocal fold injec- phonatory gap. Typically the IL is performed bilater-
tion augmentation for a variety of causes of glottic incom- ally in this group of patients.15
petence. This material requires no preparation and has no ■■ Vocal fold scar: Injection laryngoplasty may be consi­
biologic infection transmission risk.11 The substance typi- dered for a patient with a phonatory gap due to a vocal
cally lasts 2–3 months after injection.12 fold scar. The IL will allow for medialization and closure
Recently cross linked hyaluronic acid has become of the phonatory gap. At the same time injection of
more popular as it does not induce any inflammatory
steroids (often repeated at short intervals) may be given
response and it is a natural constituent of Reinke’s space.
in the superficial lamina propria (SLP) to break the
Rheologic studies have shown that hyaluronic acid based
fibrous scar tissue. The steroids must not be injected
injection materials have viscoelastic properties that best
into the muscle as this may cause muscle atrophy.
resemble that of a human vocal fold.13
■■ Neuromuscular disorders resulting in a phonatory gap:
Parkinson’s disease, motor neuron disease, mitochon-
drial dystrophy and other neuromuscular disorders
­LARYNGOPLASTY may result in a large spindle-shaped phonatory gap. In
The primary indication for IL is a phonatory gap which patients not responding to speech therapy, a bilateral
may be consequent to the following: IL can benefit such patients.
■■ Unilateral vocal fold paralysis or paresis: Patients with ■■ Trial injection laryngoplasty: Assessing the vocal bene­­
an uncompensated unilateral vocal fold paralysis or fit from a trial injection of short-term absorbable injec-
paresis are often advised speech therapy exercises. tion material such as saline or gelfoam may be useful
However, patients in whom good compensation does prior to planning IL with more permanent materials.
not take place, despite the therapy, may be advised IL
for improvement of not only the voice quality but also
in order to prevent aspiration to liquids. A permanent PATIENT SELECTION
procedure such as an approximation laryngoplasty ■■ A patient can be taken up for the procedure as long as
(type 1 thyroplasty) is usually performed only after they can withstand the procedure under local anesthe-
6–12 months, as this is the time period allowed for sia and stay in the required position for 20–30 minutes.
spontaneous vocal fold recovery. As most of the injec- ■■ The patient should be relatively comfortable with the
tion materials last for 6 months, the IL technique works laryngoscope in situ.
well as a stop gap arrangement prior to performing a
■■ Injection laryngoplasty is difficult in patients who have
permanent medialization procedure.
a complete supraglottic closure pattern.
  Occasionally patients with unilateral vocal fold
paresis, not responding well to speech therapy, are
also good candidates for the IL procedure. IL can also CONTRAINDICATIONS
be performed with saline as a trial to decide regarding ■■ Dysplasia, carcinoma in situ and malignancy of the
the benefit of the technique for a particular patient. larynx.
■■ Sulcus vocalis: Type 2 sulcus vocalis (linear vergeture) ■■ Bilateral immobile vocal folds. One vocal fold must
with a phonatory gap of less than 3 mm can also be have normal movement.16
considered for IL technique. However, as most of the ■■ Patients with bleeding disorders or on blood thinners
materials used for office procedures are temporary, a are relative contraindications for IL.
fat injection/implantation under general anesthesia
may provide with more permanent results. Once again
the IL technique may be used as a trial prior to plan-
ning a type 1 thyroplasty. The materials for IL are largely classified based on the rate
  When the phonatory gap is more than 3 mm, medi- of absorption. An ideal material should be:
alization thyroplasty improves the volume of the ■■ Biocompatible, inert and not cause local tissue reac-
patient’s voice significantly.14 tion or fibrosis
116 Section 2: Clinical Assessment and Office Procedures

Table 1: Highlighting the duration of action and specific comments regarding each implant material.
Material Duration Remarks
Saline 2–3 hours Only as trial IL
Glycerin 2–6 weeks Very short acting.
Gelfoam Up to 2 months Short-acting.
Collagen—human autologous Variable, up to 8 months Best biocompatibility, expensive
Hyaluronic acid 4-12 months Good rheology, superficial and deep use
Calcium hydroxylapatite Up to 2 years May make vocal fold less pliable, leak into the SLP causes a poor voice
Fat Variable Usually performed under GA
Silicon Permanent Extrusion of material, granuloma formation
Teflon Permanent Granuloma formation, migration, extrusion, abandoned
(IL: Injection laryngoplasty; GA: General anesthesia; SLP: Superficial lamina propria).

■■ Easy to prepare and easy to use. The injection material abundant in laryngeal extracellular matrix. The average
should be readily available, easy to measure in quan- reported duration of effect is 4 months. However, it is found
tity and easy to inject through a small needle to have at least some effect on voice up to 12 months. They
■■ Low cost are marketed with the trade name of Esthylase, Restylane,
■■ Durable, long lasting and resistant to resorption or Juvederm, Hylaform. Besides the fact that no serious side
migration effects have been reported, a distinct advantage is that the
■■ Maintain the viscoelasticity of the vocal fold postinjec- material is safe for injection in the paraglottic space as well
tion.13 as for augmentation of the SLP.
The various materials currently available are explained
in Table 1. Collagen Derivatives
They are further classified as bovine derived or human
Short-term (Up to 2 Months) derived. Ford et al. first introduced the bovine derived col-
lagen which was later abandoned due to severe allergic
Gelfoam reactions.4 The human collagen derivatives now in use are
Gelfoam is composed of purified bovine gelatin powder and Cymetra, Cosmoplast or Cosmoderm.
requires reconstitution. Frequently used as an injectable in They last for a reported duration of 4–8 months. Colla-
“trial laryngoplasty”, it lasts for a duration of 4–10 weeks and gen derivatives are contraindicated in patients with mixed
is a good means of temporary medialization. It has shown connective tissue diseases.
a 2% risk of allergy in injected patients. The injection of gel-
foam paste results in minimal tissue reaction.17 Long Term (1–2 Years)
Calcium Hydroxylapatite
Carboxymethylcellulose (Voice Gel)
Microspheres of calcium hydroxylapatite in glycerin-based
Carboxymethylcellulose is composed in a glycerin water
gel are used. An overinjection of 10% of the injectable is
based gel. It undergoes rapid absorption within a period
performed in anticipation of gel absorption which lasts
of 1–2 months but has the advantage of providing superior
for a reported duration of 1–2 years. However, they have
vibratory outcomes of the vocal fold mucosa.
an inferior vibratory outcome as compared to hyaluronic
acid derivatives.18
Intermediate (2–12 Months)
Hyaluronic Acid Derivatives Autologous Fascia
This group of injectables is composed of various modifi- Fascia lata, Rectus sheath or Temporalis fascia can be har-
cations of hyaluronic acid, a glycosaminoglycan naturally vested from the same patient. Fascia lata is the preferred
Chapter 10: Injection Laryngoplasty 117

donor site owing to the abundance of tissue and easy under general anesthesia. The office procedure can be
access.19 The autologous fascia is minced after harvesting performed as a percutaneous IL, fiberoptic IL or as a trans­
and injected into the paraglottic space. It stays up to a year, oral IL.
however results are unpredictable. Recent study by Rei-
jonen et al. showed that the postinjection results can last PERCUTANEOUS OFFICE INJECTION
ranging from 3 years to 10 years.20
Permanent Injection laryngoplasty is a relatively simple office-based
procedure but requires two trained physicians to perform
Teflon the technique comfortably and accurately. The impor-
tance of having a good assistant cannot be overempha-
It is composed of polytetrafluoroethylene and it is perma-
sized as it is essential to have a good view of the vocal folds
nent, however, its use has been limited due to a very high
during the procedure which aids in precision of the entire
incidence of Teflon granuloma formation (granulomatous
technique (Fig. 1).
foreign body reaction).21
Equipment Required
A tray is prepared with the required equipment prior to the
Silicon is a permanent material and has been compared procedure (Fig. 2):
to medialization thyroplasty. However, there have been ■■ The injection material
several reports of granulomatous reaction, extrusion and ■■ A flexible laryngoscope or a bronchoscope with a side
migration following the injection. channel
■■ Laryngeal injection needles—22 G, 25 G, 27 G
Autologous Fat ■■ 2 cc/5 cc syringe
■■ Local anesthetic—2% lidocaine with adrenaline
The fat is harvested from the patient and the procedure
■■ Xylometazoline—0.1% nasal solution
is typically performed under general anesthesia. The
■■ 10% lidocaine spray and 4% lidocaine solution.
autologous nature makes it biocompatible and safe for
use.22 The results may vary as fat may last from a few
weeks to lifelong. We have observed that if the fat stays
for a period of 6–8 weeks, then the results are usually A written consent is taken from the patient after explaining
permanent. the procedure in detail. Injection glycopyrrolate (1 mL) is
There are different modalities of harvesting fat: given intramuscularly half an hour before the procedure.
■■ Making an incision over the lateral aspect of the thigh This has the added advantage of drying up secretions
or periumbilical region after infiltration with lidocaine making IL easier. Nebulization of 4% lidocaine is given for
with adrenaline at the site. 5–10 minutes to the patient. The nostrils are decongested
■■ Liposuction: Once the fat is harvested it is washed with xylometazoline spray and anesthetized with 4%
with 1–2 L of saline in order to get rid of all the fatty lidocaine spray. The procedure may be performed under
acids as these fatty acids are thought to be respon- constant SpO2 monitoring.
sible for inflammation. Following this the fat pieces The percutaneous technique for IL was first introduced
are placed in human insulin for 3–5 minutes in order by Ward et al. in the year 1985. This technique was opted
to stabilize the fat cell wall. The fat is then washed for and popularized in patients with anatomical deform-
in Ringer’s lactate and finally chopped into a fine ity of the face, trismus or for other reasons in which visu-
paste-like material. This material has to be injected alization of the larynx trans-orally was a challenge.23 The
under high pressure using a Bruening’s syringe and paraglottic space can be accessed percutaneously from
18-gauge needle or an 18-gauge butterfly scalp vein the transthyroid route, thyrohyoid space or the cricothy-
with its wings cut and held by a crocodile forceps. roid space. Each approach has its own unique advantages
Injection laryngoplasty can be performed as an office and drawbacks. For all the percutaneous techniques the
procedure or in the operation theater with the patient patient is sitting with neck extension and a head support
118 Section 2: Clinical Assessment and Office Procedures

Fig. 1: Photograph showing the positioning of the patient, doctors Fig. 2: The equipment required for injection laryngoplasty (IL)
and equipment. arranged on a trolley.

Fig. 4: Surface markings over the neck showing the thyroid notch
(+), inferior border of thyroid cartilage (yellow arrow) superior and
Fig. 3: Position of the patient with neck extension for injection inferior border of cricoid cartilage (green arrows) and the shaded
laryngo­plasty (IL) technique. area showing cricothyroid membrane (red cross).

(Fig. 3). The surface markings of the thyroid and cricoid head support in a sitting position. The laryngologist pal-
may be made for the first few cases (Fig. 4). pates and if necessary marks the hyoid, thyroid and cricoid
cartilages in the neck. The flexible bronchoscope/laryn-
Transthyroid Technique goscope is inserted transnasally and subsequently held
by the assistant with a good close-up view of vocal folds.
The transthyroid approach for IL is the most direct approach Via the side channel of the flexible scope, 4% lidocaine is
which in nonossified thyroid cartilages,24 in thin necked introduced which acts as a laryngeal gargle. An a­ lternative
patients, is possibly the easiest approach. The skin over the technique of anesthesia is direct injection of 2–3 cc of
lower border of thyroid cartilage in the midline is injected lidocaine via the cricothyroid route. With a finger, pressure
with 2 cc of 2% lidocaine with adrenaline after cleaning is applied over the cricothyroid membrane as this provides
with a spirit swab. The patient is given a neck extension with a good indication of the vocal fold level in comparison to
Chapter 10: Injection Laryngoplasty 119

Fig. 5: Showing points of insertion of needle in various technique.

Red circle: Thyrohyoid technique; Yellow square: Transthyroid
technique; Green rhomboid: Cricothyroid technique. Fig. 6: Diagrammatic illustration of transthyroid technique.

Figs. 7A and B: (A) Transthyroid injection laryngoplasty being performed for a patient with bilateral multiple sulci (red arrows); (B) Bal-
looning of left vocal fold seen in the same patient due to injection material (yellow arrow).

surface markings. For transthyroid IL a 21-G/22-G needle vocal fold and the needle can be moved anteriorly and
is used, as a thinner needle than this tends to get blocked posteriorly as warranted. Typically 0.3–0.6 cc of material
by the cartilage itself. Using a boring action the needle is is injected into the paraglottic space causing a ballooning
introduced perpendicular to the thyroid ala, 2–3 mm from and medialization of the true vocal fold (Figs. 7A and B).
the lower border of thyroid cartilage and 4–5 mm from the
midline (Figs. 5 and 6). Conversion to the cricothyroid approach: If the thyroid
A give way sensation is typically felt twice (when the ­cartilage ossification does not allow for this technique, the
needle passes through the outer and inner laminae). It needle is stepped down by 1–2 mm up to the lower b ­ order
is important not to pierce the needle into the laryngeal of the thyroid cartilage. It is then introduced into the
lumen as that would cause egress of the injection material ­cricothyroid membrane by 1–2 mm and then the ­needle
into the airway. A movement and “tenting up” of the vocal is directed upward to enter the infraglottic surface of the
fold is closely looked for at the level of the membranous vocal fold in the submucosal plane.
120 Section 2: Clinical Assessment and Office Procedures

cleaned with a spirit swab and 2% lidocaine with adren-

aline is injected just above thyroid notch in the midline. A
25-G needle is introduced just above thyroid notch in the
midline (Figs. 10A and B). This needle pierces the petiole of
epiglottis at which point there may be bleeding (especially
in case of patients on blood thinners). Agents such as
hemlock (aminocaproic acid) may be used to control
bleeding and may be introduced via the side channel of
the scope. The needle is advanced in a downward and
lateral direction so that the tip of the needle can be intro-
duced into the paraglottic space just lateral to the vocal
process of arytenoid or more anteriorly if indicated. Some
surgeons like to bend the hub of the needle toward the skin
caudally so that the needle can be directed inferiorly more
easily. Two bends may also be made in the needle prior to
Fig. 8: Diagrammatic illustration of cricothyroid technique. insertion.

Flexible Endoscopic Injection Technique

Cricothyroid approach: This technique was first performed
by Ward et al. in 1985 as the first method of percutaneous Flexible endoscopic IL may be performed under local
injection for vocal fold augmentation.23 Infiltration of 2% anesthesia and requires the use of flexible endoscopes
lidocaine with adrenaline over the cricothyroid mem- with a working channel through which a fine injection
brane in the midline is performed following the skin needle (23–25 G) can be passed. These needles are primed
being cleaned with a spirit swab. A 27-G needle is bent 30° with the injection material to eliminate the dead space
upward and introduced 1–2 mm from the midline in the within the needle. This technique has been advocated
cricothyroid membrane hugging the lower border of the using a dilute concentration of micronized deep dermal
thyroid cartilage (Figs. 5 and 8). tissue (micronized collagen), mixed with 2.3 mL of 1%
The needle is directed 30° laterally and the material is lidocaine for all cases.27
injected into the undersurface (infraglottic surface) of the However this method is technically demanding and
vocal fold. The injection is given submucosally and the needs expertise in performing the procedure. It should
infraglottic bulging is noticed (Figs. 9A to F). also be noted that due to the length and caliber of the
It is not essential to perform the cricothyroid injection injection needle, this approach requires more than the
submucosally. The needle (25 or 26-gauge) may be intro- normal amount of injection material to accommodate the
duced 1–2 mm off the midline into the laryngeal lumen via relatively large dead space in the needle, thus making this
the cricothyroid space and directed toward the contralat- approach less cost-effective.11
eral vocal fold posteriorly.
Injection laryngoplasty procedure can be performed Peroral Injection Technique
safely on both vocal folds as long as both the vocal folds Per oral injection technique is performed with a curved
are mobile (sulcus vocalis, presbyphonia). The patient is needle passed through the mouth under the guidance of
asked to cough so as to spread the injection material and flexible laryngoscope or a rigid laryngoscope (Fig. 11). The
if a phonatory gap persists then further augmentation may
patient is seated on a chair with head slightly extended
be performed.
and with flexion of the neck (sniffing position). A good
Thyrohyoid approach: This was first introduced and popu- local anesthesia is essential for this procedure. Several
larized by Milan Amin in 2006.25 The thyrohyoid injection needles are available commercially which are usually of
involves entering the laryngeal lumen, therefore suffi- the length 220–250 mm.11 The needle is passed through the
cient anesthesia is of utmost importance. This approach mouth and into the paraglottic space of the vocal fold by
is advantageous in that it allows needle placement under retracting the false vocal fold with the shaft of the needle
direct visualization.26 The skin over the thyroid notch is to visualize the lateral part of true vocal fold. The whole
Chapter 10: Injection Laryngoplasty 121


Figs. 9A to F: Right immobile vocal fold seen in a lateral position with a prominent right vocal process (red arrow); (B) Tenting with
bulging of anterior part of right vocal fold (red arrow) due to insertion of 22-G needle; (C) Further ballooning of right vocal fold (red arrow)
with a resultant less prominent right vocal process (green arrow); (D) The injection material is now seen to cause medialization even at
the level of vocal process (red arrow); (E) Planned overmedialization of right vocal fold; (F) Tenting of right vocal fold (red arrow) seen
in another patient while performing submucosal cricothyroid technique.

Figs. 10A and B: (A) A 25-G needle tip seen

piercing the petiole of epiglottis in thyrohyoid
technique (green arrow); (B) Diagrammatic
A B illustration of thyrohyoid technique.
122 Section 2: Clinical Assessment and Office Procedures

Fig. 11: Diagrammatic illustration of transoral technique.

Fig. 12: The tip of the laryngeal needle is inserted lateral to the
procedure is performed under the guidance of a flexible vocal ligament under direct vision in microlaryngoscopic technique.

laryngoscope or a rigid laryngoscope. An assistant holds

the flexible scope or the tongue in the case when a rigid
Microlaryngoscopic Injection ■■ A temporary airway compromise due to:
It is performed under general anesthesia with suspension ◆◆ Laryngospasm
laryngoscopy. A 25-cm long, 18-gauge, bayonet-shaped ◆◆ Laryngeal edema.
needle attached to a Bruening’s syringe is passed through a ■■ Allergy to the injected material.
rigid laryngoscope under direct microscopic visualization. ■■ Risk of bleeding—low but usually seen in patients with
The material (usually fat) is injected into the paraglottic deranged clotting parameters.
space by retracting the false vocal fold laterally with the
needle tip and shaft. The injection is performed just ante-
■■ Having a colleague while performing IL is of paramount
rior to the vocal process and as laterally as possible. Either a importance
Bruening’s syringe is used or an 18-G scalp vein may be ■■ Be conversant with more than one technique while per-
used. The medialization of vocal fold can be visualized forming IL
under the microscope (Fig. 12). The exact amount of mate- ■■ Performing the procedure in an awake patient has the
rial required cannot be estimated and overinjection or advantage of assessing the patients voice and phonatory
gap during the procedure, which enables the surgeon to
underinjection is a drawback in this technique. Injection
decide the amount and exact placement of the material
can also be performed in the SLP in cases of sulcus or scar- being injected. Performing IL in awake patient enables the
ring in which case the needle is walked 1 mm anteriorly surgeon to inject the correct amount in the right place, by
from the point of introduction in order to minimalize the listening to the voice quality and assessing the phonatory
egress of the fat. gap.
If fat is not being injected, then a 27-gauge needle is ■■ In the beginning of ones learning curve, it is safer to use
injection material that will not worsen a patients voice even
preferred and a high pressure syringe is not warranted.
if it leaks into the SLP.
The patient may be injected without any endotracheal ■■ One vocal fold must be mobile while performing IL
tube and if a small five number tube is used then care is
taken to facilitate a smooth extubation without severe
coughing and retching. FUTURE RESEARCH
Underinjection results in undercorrection of the Injection laryngoplasty as a technique for vocal fold medi-
pathology resulting in unsatisfactory results. alization has evolved over the century. It has progressed
Chapter 10: Injection Laryngoplasty 123

from the use of indirect laryngoscopy to inject the material 12. Kwon TK, Rosen CA, Gartner-Schmidt J. Preliminary results
into the vocal fold in the early 1900s to the use of flexible of a new temporary vocal fold injection material. J Voice.
laryngoscopes. However, the search for an ideal material
13. Karagama Y, Phua CQ, Gappa YM, et al. Injection
which can last a lifetime and is completely biocompatible Laryngoplasty. Otorhinolaryngologist. 2013;6(2):111-8.
is still in process. 14. Andrews BT, VanDaele DJ, Karnell MP, et al. Evaluation
of open approach and injection laryngoplasty in revision
thyroplasty procedures. Otolaryngol Head Neck Surg.
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Office-Based Vocal
Fold Procedures

Phaniendra Kumar Valluri

INTRODUCTION Unsedated awake vocal fold procedures can be either

vocal fold injection (VFI) techniques or laser assisted
Until 1960s, most laryngeal endoscopies were performed
surgeries for removal of benign or premalignant growths.
with the patient awake using rigid instruments and tech­
As most of these awake laser-assisted laryngeal surgeries
niques described by Jackson.
are commonly performed in the office or endoscopy suite,
In the last decade, the focus has been on the growth
they are popularized as unsedated office-based laryngeal
and development of “minimally invasive” methods for laser surgeries (UOLS).
both diagnosis and treatment.
A technological revolution has occurred in otorhino­
laryngology rendering significant advances in flexible
endoscopes, laser delivery systems, and topical anesthe­ ­PROCEDURES—APPLICATIONS
sia, making it possible to perform surgery and many other ■■ Vocal fold injection techniques
laryngeal procedures safely on unsedated awake patients ■■ Vocal fold biopsies
either in the office setup or in the operating room, with ■■ Office-based laser-assisted laryngeal surgeries for
excellent results and patient acceptance. The major reason various benign and premalignant growths of the vocal
why office procedures will increase in popularity is based folds.
on patients acceptance.1 Most of these unsedated vocal fold procedures are
done in outpatient as office based except in certain situ­
HISTORICAL ASPECTS ations like fat injection laryngoplasty which is done in the
operating room as fat has to be harvested in the operating
1872: Jacob Solis Cohen performed the first office-based room under sterile conditions.
mirror guided surgery at his home in Philadelphia.2
1970s: Introduction of flexible fiberoptic scopes Preparation and Selection of the Patient3
allowed examination of awake, unsedated patients in the
■■ Counseling with informed consent is essential for all
office. It is useful to have closer view of vocal folds for patients and assessment is necessary for gag reflex,
assessing the dynamic phonation. anxiety, and pain tolerance.
1999: Distal-chip camera for flexible aerodigestive tract ■■ It is advisable to exclude cardiopulmonary disease or
endoscopy [transnansal esophagoscopy (TNE), 5.1 mm movement disorders or any other comorbid conditions.
diameter] or 4.1 mm diameter flexible laryngoscope with ■■ Better to avoid anticoagulant drugs during the proce­
brilliant illumination, high resolution, working channel dure.
(2 mm) suction was introduced.2 ■■ Nasal patency should be assessed for transnasal
2004: Zeitels et al. described office-based 532 nm procedures.
pulsed-KTP (potassium titanyl-phosphate) laser treat­ ■■ Adequate mouth opening of at least 2 cm is essential
ment of glottal papillomatosis and dysplasia. for transoral instrumentation.
Chapter 11: Office-Based Vocal Fold Procedures 125

Fig. 1: Office-based vocal fold procedures done in sitting position Fig. 2: Office-based vocal fold procedures done in lying position
in the office chair. in the endoscopy suite.

Position of the Patient Most commonly followed and recommended proce­

dure is to administer:
Most of the unsedated awake office-based laser vocal fold ■■ Topical oxymetazoline and 4% lidocaine spray into
surgeries are traditionally done while the patient is sitting nasal cavities or topical nebulized solution of 2% lido­
in the office chair (Fig. 1) and sometimes in lying posture caine and 0.125% phenylephrine intranasally.
or supine position in selected patients on an endo­scopy ■■ Epinephrine and 4% lidocaine solution cotton or new-
coach in endoscopy suite (Fig. 2) for the following reasons: gauze packed in one side of the nose.
■■ Patient feels secured with good hemodynamic stability4 ■■ Topical spray of 4% lidocaine on the palate and poste­
particularly very elderly patients or children. Clinicians rior pharynx.
should be aware of significant changes in hemo­ ■■ Drip 3–5 mL of 4% lidocaine onto the tongue base and
dynamic status and consider the risks produced by larynx under fiberoptic guidance.
these changes to their patients.5 ■■ Superior laryngeal nerve block in selected cases.
■■ Less chances for vasovagal syncope compared to ■■ Nothing per orally allowed for 45–60 minutes following
sitting position. This could be explained by diffusion of procedure.
anesthetic to the carotid bulb or the main trunk of the
vagus.5 Office-based Vocal Fold
■■ Endoscopy maneuvers are much easier both for the
Injection Techniques
surgeon and the assistant.
■■ Preferable in prolonged procedures. Compared to similar procedure under general anesthesia
in the operating room, when the procedure is done awake,
Methods of Topical Anesthesia for the patient can talk during the procedure, the amount of
material can be judged, and the result of injection can be
­Office-based Vocal Fold Procedures
assessed instantaneously. Moreover, risks are few and also
Sulica L and Blitzer A5 described a standardized protocol the procedure is cost effective.
to achieve laryngeal anesthesia in office setup with three Vocal fold injection techniques can be superficial or
basic components, bilateral superior laryngeal nerve deep injections.
block, topical anesthesia of the trachea via cricothyroid Vocal fold injection techniques with injections into the
puncture, and peroral topical anesthesia of the larynx and superficial (subepithelial space) aspect of the vocal fold
pharynx. Nothing per orally allowed for 45-60 minutes provide correction of vibratory defects. Useful for mild-to-
following procedure.5 moderate vocal fold scar and lamina propria defects.
126 Section 2: Clinical Assessment and Office Procedures

Deep or lateral injection, as a means for vocal fold

augmentation allows for correction of glottal insufficiency
from a variety of causes.
Patient selection is critical when choosing VFI in an
awake patient; a cooperative, calm patient without a strong
gag reflex is required for successful completion.

Indications for Office-based

Vocal Fold Injection Techniques
■■ Superficial injection techniques indicated in vocal fold
scar, lamina propria defects, or sulcus vocalis.
■■ Deep injection techniques are indicated for mediali­
zation of vocal fold as in cases of vocal fold paralysis,
paresis, or atrophy or bowing of vocal fold (presby­ Fig. 3: Percutaneous vocal fold injection (VFI) technique crico­
larynx). The various injection materials used are thyroid approach.

Teflon, Gelfoam, fat, collagen, various gels, hyaluronic

acid, or calcium hydroxylapatite (CaHA), etc.
Transoral Vocal Fold Injections Assisted
OFFICE-BASED VOCAL FOLD INJECTION with Transnasal Flexible Endoscopy
TECHNIQUES—APPROACHES Transoral VFI approach utilizes a direct approach with
good needle visualization. In spite of proper topical anes­
Typically three approaches are performed with a flexible thesia of the oropharynx and larynx, patient cooperation
laryngoscope in place, visualizing the larynx and moni­ especially those with severe gag reflex is a critical problem
toring the injection effects. In most cases, optimal visua­ as the needle is guided from the mouth to the vocal fold.
lization is provided with a distal chip laryngoscope with The patient is seated in sniffing position in an office chair
digital, high-quality video image output. and a flexible laryngoscope is inserted through the nose
1. Total transnasal endoscopic vocal fold injections while the patient protrudes and holds the tongue. Topical
2. Transoral vocal fold injections assisted with transnasal anesthetic is applied through a flexible catheter directed
flexible endoscopy through the working channel of a flexible laryngoscope
3. Percutaneous transcervical vocal fold injections onto the base of tongue, epiglottis, and the true vocal folds
assisted with transnasal flexible endoscopy. during phonation. The route of the needle is usually a 90°
path, variable from patient to patient. Several commer­
Total Transnasal Endoscopic cially available needles with lengths of 220–250 mm are
used for transoral VFI.
Vocal Fold Injections
Transnasal endoscopic approach to the vocal fold utilizes Percutaneous (Transcervical) Vocal
a flexible working channel laryngoscope with a 23- or
25-gauge flexible needle introduced through the working
Fold Injections Assisted with Transnasal
channel, and the needle can be guided to the appropriate Flexible Endoscopy
lateral position under direct visualization. The fine gauge Percutaneous injection aims to medialize a patient’s vocal
injection needles only accommodate dilute preparations fold. There are three approaches: (1) through the thyro­
like steroids (dexamethasone or trimacinalone). It should hyoid membrane; (2) through the thyroid cartilage or;
also be noted that due to the length of injection needle, (3) through the cricothyroid membrane (Fig. 3).
this approach requires more than the normal amount of The nasal cavity and larynx are anesthetized as
injection material to accommodate the relatively large described above. The skin over the site of injection is
dead space in the needle. anesthetized with 1% lidocaine injection specific to each
Chapter 11: Office-Based Vocal Fold Procedures 127

approach. The surgeon then passes the needle through the COMPLICATIONS OF VOCAL FOLD
skin via one of the three approaches.
Transthyrohyoid Membrane Approach ■■ Allergic reactions to injected compounds
■■ Foreign body reactions can occur to any product,
Usually preferred in males and the approach utilizes an including the patient’s autologous tissue
extramucosal route to the vocal fold. The needle is inserted ■■ Rarely bleeding and breathing difficulties.
into the skin overlying the thyroid cartilage notch through
the thyrohyoid membrane and enters in pre‑epiglottic
space above the vocal folds and directed towards the vocal
fold under the flexible endoscopy guidance. Among the AND LARYNGEAL LASER SURGERIES
percutaneous techniques, the transthyrohyoid membrane Advances in techniques of anesthesia and invention of
approach has the advantage of direct visualization of the flexible nasopharyngo-laryngoscopes of smaller diameter
needle increasing precision of the injection. (4.1–5.1 mm) with distal chip imaging technology, incor­
porated with working or suction channel have revolution­
Transthyroid Cartilage Approach ized the office-based laryngeal procedures. Emergence of
small flexible laryngoscopy forceps and laser fibers of dif­
This approach is better used in younger patients before the ferent wavelengths made biopsies and other many laryn­
thyroid cartilage has ossified. In this approach, the vocal fold geal procedures technically easier and safer.
is approached laterally and the needle is passed through the Awake UOCL is a safe, well-tolerated procedure that
skin and thyroid cartilage and then into the vocal fold. treats various benign and premalignant growths of the
A needle is inserted 3−5 mm above the lower border vocal folds. When compared to laryngeal procedures
of the thyroid cartilage and passed gently through the car­ under general anesthesia in an operating room, it has the
tilage and advanced towards midline under transnasal following advantages:
flexible endoscopy control avoiding mucosal violation. Occa­ ■■ As all the procedures are done under local anesthesia,
sionally, obstruction of the needle with cartilage may occur, patient requires no admission or postoperative reco­
necessitating excessive pressure during injection of material. very, thus minimizing the postoperative time and cost.
■■ Office-based laryngeal procedures are relatively safe
Transcricothyroid Membrane Approach with fewer complications and increased patient’s
This is preferred approach in females. Needle is passed satisfaction.
in the midline of the neck through the cricothyroid mem­ Unsedated office-based laser surgery of the larynx and
brane. It is visualized passing into the airway underneath trachea has significantly improved the treatment options
the true vocal fold and inserted into the paraglottic space. for patients with laryngotracheal pathology including
The transcricothyroid membrane approach typically recurrent respiratory papillomas (RRP), granulomas,
utilizes a submucosal path. A 25 g needle, bent 45° is leukoplakia, and polypoid degeneration.
inserted below the inferior border of the thyroid cartilage,
3–7 mm lateral to midline and subsequently passed cepha­ Technique of Anesthesia6
lad and laterally. This approach is most commonly prac­ First, the nose is sprayed with ephedrine and pontocaine
ticed. Percutanous VFI technique is indicated for injection solution or with 10% lidoocaine with xylometazoline solution
of Botox in cases of spasmodic dysphonia. The reader can and then cotton or new-gauze soaked in 4% lidocaine is
find details about this in the other chapters of this book. packed on one side of the nose. The nasal packing is left
Alternatively, with adequate tracheal anesthesia, the in for 10−20 minutes; and sometimes the patient will note
needle can also be inserted into the midline in the infra­ that his or her incisors feel numb. Adequate nasal anes­
glottis, and then directed superior and lateral, intralumi­ thesia is important. Generally, three or four sprays of 4%
nally, to the deep aspect of the vocal fold. This technique lidolocaine are needed. That means if 5.0 mL of anesthetic
is frequently followed for medialization of vocal fold with is squirted through the fiber optic laryngoscope into the
a variety of materials like Gelfoam, fat, collagen, various endolarynx approximately 1.5 to 2 mL of anesthetic will
gels, hyaluronic acid, or CaHA, etc. be delivered and the rest will be suctioned up.
128 Section 2: Clinical Assessment and Office Procedures

The first squirt is delivered from above the palate; Selection of Wavelength of Laser for
the second is aimed at the epiglottis and valleculae, and
Unsedated Office-based Laryngeal
the third (and fourth) are squirted into the endolarynx.
The author recommends having the patient phonate a
Laser Surgeries
sustained vowel and squirt at the end of the breath. It is Unsedated office-based laryngeal laser surgery had its real
worth noting that the posterior larynx is more difficult to origins with the pulsed-dye laser (PDL).7 At 585 nm, it is
anesthetize. primarily absorbed by hemoglobin. UOLS has been shown
to be safe and effective, especially for RRP. One of the chief
Position of Patient advantages of the PDL wavelength is that both sides may
be treated at the anterior commissure without significant
Patients for office-based laryngeal biopsies or UOLS are
risk of web formation. In addition, for certain lesions such
conventionally done in sitting position in the office chair
as polypoid degeneration, it may be the wavelength laser
except in certain special situations like when the patient
of choice.2
has lot of anxiety and in children, the author prefers lying
The pulsed KTP laser is very delicate allowing vocal
position on an endoscopy coach in an endoscopy suite.
cord lesions to be removed with minimal damage to vocal
fold tissue, thus preserving the natural voice. 532 nm
Approach pulsed KTP laser provides enhanced performance over the
Transoral route: Curved and angulated laryngeal instru­ PDL laser in a number of ways. The ability to use smaller
ments are passed per orally guided with transnasal flexible glass fibers precluded mechanical trauma to the channels
laryngoscope passed by the assistant for laryngeal biopsies. of the flexible laryngoscopes and allowed for improved
Total transnasal route: Most commonly followed now­ suctioning of secretions.7 It is ideal for patients with
adays using chip on tip of 5 mm flexible laryngoscope reoccurring conditions because it does less damage to the
with a working or suction channel through which either vocal folds. The 2013 nm Thulium laser shows promise as
biopsy forceps or laser fiber is passed for laryngeal biopsy an office-based laser that simulates the properties of the
or removal of benign vocal fold lesions. It is advisable to carbon dioxide laser.7
have at least two flexible laryngoscopes with right and left Franco et al.8 reported their series of 41 cases of recur­
working channels. rent papillomatosis of the glottis. Of these groups 26 cases
had been treated with PDL alone and a complete or nearly
OFFICE-BASED (VOCAL FOLD) complete resolution was seen in all 26 cases and there
were no complications.
Recently, a CO2 laser beam delivered through a flexible
This laser technology is useful to treat vocal cord lesions hollow tube has become available that delivers the beam
such as polyps or tumors, as an outpatient treatment with­ close to the target. However, the use of diode laser by
out anesthesia. It is also an ideal approach for patients contact (or extremely close distance) makes it much safer
with recurring conditions that require regular treatment, than other laser sources by avoiding damage due to “beam
such as laryngeal papilloma or laryngeal dysplasia. scape” in an open field.
Fiberoptic flexible laryngoscopy of 5 mm diameter The 980 nm diode laser is a new technology, and has
with working (biopsy and suction) channel is passed been reported for the treatment of early glottic tumors
through patient nose until larynx and disease visualized. and vocal fold polyps since 2013.9 The diode laser has
Vocal fold biopsy can be taken using flexible laryngo­ excellent hemostatic properties as a result of high
scopy biopsy forceps passing through the working channel absorption by hemoglobin and particularly by oxyhemo­
of the scope. Vocal polyps or papillomas or dysplastic globin. The 980 nm diode laser seems to be a promising
lesions can be debulked or removed totally with laser. laser device. It is also absorbed by water, but less so than
Either a noncontact (beam) or contact laser, laser fiber is the CO2 laser. Furthermore it is portable, small, relatively
advanced several millimeters through the working chan­ inexpensive, and simple to use. It also has stable power
nel until it is in the visual field at a distance of 2 mm to the output, long lifetime, and low installation and mainte­
tissue and then applied for excision of the lesion. nance costs.9 Author’s choice is Diode laser in his office
Chapter 11: Office-Based Vocal Fold Procedures 129

for office based vocal fold surgeries. About 525 office As training in endoscopic procedures improves, sur­
based vocal fold surgeries were done since 2005 with geons may perform procedures more and more as office
acceptable voice outcomes and without any complications. based even for the procedures that are technically difficult
in the operating room setting.
Limitations of Office-based Laryngeal
Laser Surgeries2 REFERENCES
1. Woo P. Office-based laryneal procedures. Otolaryngol Clin
Good practice needed for handling on the moving target:
N Am. 2006;39:111-33.
■■ Difficult to quantify energy delivery and real-time 2. Koufman JA, Rees CJ, Frazier WD, et al. Office-based laryn­
tissue effects geal laser surgery: a review of 443 cases using three wave­
■■ May not be possible to take biopsy. lengths. Otolaryngol Head Neck Surg. 2007;137:146-51.
3. Koufman JA. Introduction to office-based surgery in laryn­
gology. Curr Opin Otolaryngol Head Neck Surg 2007;15:
Contraindications for Office-based 383-6.
­Laryngeal Laser Surgeries2 4. Yung KC, Courey MS. The affect of office-based flexible
endoscopic surgery on haemodynamic stability. Laryngo­
■■ Bulky papillomatosis scope. 2010;120:2231-6.
■■ Difficulty to reach locations like ventricle. 5. Sulica L, Blitzer A. Anesthesia for laryngeal surgery in the
office. Laryngoscope. 2000;100:1777-9.
6. Simpson CB, Amin MR, Postma GN. Topical anesthesia of
CONCLUSION the airway and esopha­gus. Ear Nose Throat J. 2004;83:2-5.
7. Zeitels SM, Burns JA. Office-based laryngeal laser surgery
The awake office-based laryngeal procedures offer numer­
with the 532-nm pulsed-potassium-titanyl-phosphate laser.
ous advantages to the patient and surgeon. They are Curr Opin Otolaryngol Head Neck Surg. 2007;15:394-400.
well-tolerated, safe, and can be used to treat a wide variety 8. Franco RA. In office laryngeal surgery with the 585-nm
of laryngeal pathologies. pulsed dye laser. Curr Opin Otolaryngol Head Neck Surg.
Vocal fold injection is a proven technique with favora­ 2007;15:387-93.
9. Arroyo HH, Neri L, Fussuma CY, et al. Diode Laser for
ble results for the treatment of mild-to-moderate glottic
Laryngeal Surgery: a Systematic Review, Int Arch. Otorhino­
insufficiency due to a variety of causes. larngol. 2016;20(2):172–9.
130 Section 2: Clinical Assessment and Office Procedures

Laryngeal Electromyography in
Spasmodic Dysphonia and
Overview of Spasmodic Dysphonia
Eric Barbarite, David E Rosow

INTRODUCTION often fatigued due to overexertion against a hyperadducted

glottis.5 Abductor dysphonia occurs less frequently, and
Spasmodic dysphonia (SD) is a dystonic condition of the may present as breathy and hypophonic speech or abrupt
laryngeal musculature resulting in a constellation of vocal loss of voice due to vocal fold hyper­abduction during pho­
symptoms and reduced quality of life. Adductor, abductor, nation.5 Lastly, mixed SD represents an entity with signs
and mixed subtypes of SD make it a heterogeneous disor­ and symptoms of both adductor and abductor dysfunc­
der that may manifest as distinct or overlapping clinical tion.6 Patients often report a gradual onset of vocal changes
pictures. Electromyography (EMG) provides an objective over months to years, followed by a plateau in symptoms;
means to characterize laryngeal muscle activity and guide however, a more sudden onset has also been described.7
management of SD. The focus of this chapter is to pro­ Laryngeal electromyography serves as an important
vide an overview of SD and laryngeal electromyography adjunct to the evaluation and diagnosis of laryngologic
(LEMG) and to examine the role of LEMG in the diagnosis disease. LEMG relies on the potential differences across
and treatment of SD. cell membranes, which are established by intracellular
Spasmodic dysphonia is a focal dystonia of the larynx and extracellular ion gradients.8 When an appropriate
characterized by poor vocal motor control. SD occurs in stimulus is applied via electrode, an action potential is
roughly 1 in 10,000 persons and most commonly presents generated that may be detected by EMG.8 A motor unit
during the 5th and 6th decades of life. The incidence of SD consists of a lower motor neuron and the muscle fibers it
is higher in females, with a female to male ratio ranging innervates. The ratio of muscle fibers to lower motor neu­
from 2.6 to 4:1.1 Despite these trends, the etiology of SD rons serves as a representation of muscle function.9 A high
remains unknown. Initial descriptions attributed the con­ innervation ratio suggests a muscle is involved in gross
dition to psychogenic causes; however, psychiatric assess­ movements, whereas a low innervation ratio is indicative
ments fail to show a difference between SD and control of fine motor function. Given the intricacies of phonation
patients.2,3 Patients with SD do not demonstrate a higher and the need for precise muscle movements, the innerva­
incidence of major illnesses or neurological disorders. tion ratio of the laryngeal musculature is quite small.8 The
No significant environmental or hereditary patterns have purpose of LEMG is to characterize spontaneous activity,
been established; however, there may be a greater rate of single motor unit potentials, and recruitment potentials of
childhood viral illness and concurrent essential tremor.1 the laryngeal muscles.10
Abnormalities involving the basal ganglia and peripheral Laryngeal electromyography detects bioelectric poten­
myelination have also been posited.4 tials via an active recording electrode that is connected
Spasmodic dysphonia may be classified into various to an amplifier with preset bandwidth and impedance.
subtypes based on the pattern of vocal fold movement. The typical LEMG waveform is biphasic with amplitude
Adductor SD represents the most common form (80%) and between 200 μV and 600 μV and duration of 3–6 milli­
is characterized by vocal strain due to irregular adduction of seconds; however, variations exist among the indivi­
the vocal folds during speech. Patients may exhibit tremor, dual laryngeal muscles.11 Electrical data from LEMG are
vocal fry, inappropriate pitch, and breathiness, and are often paired with speech by way of a separate channel for
Chapter 12: Laryngeal Electromyography in Spasmodic Dysphonia and Overview of Spasmodic Dysphonia 131

voice signal. A reference electrode is also connected to the team consisting of an otolaryngologist, speech language
amplifier. Routine LEMG is performed using a mono­polar or pathologist, and neurologist. The diagnostic role of the
concentric needle electrode.12 Concentric needle ­electrodes otolaryngologist primarily relies on clinical history, pho­
deliver a small recording area than mono­polar electrodes, natory evaluation, and laryngoscopy. EMG offers an addi­
which allows for more stable background activity and less tional means to objectively characterize laryngeal muscle
interference by surrounding musculature. Moreover, con­ activity, and it has allowed for greater insight into the
centric needles are more durable and penetrate cartilage behavior and treatment of SD. For example, LEMG data
and soft tissue with greater ease.11 The use of local anes­ suggest that lower motor neuron pathology does not play
thesia during electrode insertion is not recommended due a role in the etiology of SD, as evidenced by the absence of
to its effects on neuromuscular signal transmission.13 fibrillations, sharp wave potentials, or reduced motor unit
recruitment potentials in patients with SD.10,20,21
Routine LEMG measures activity of the cricothyroid
HISTORICAL ASPECTS (CT), TA, and posterior cricoarytenoid (PCA) muscles.
Spasmodic dysphonia was originally described by Traube Successful evaluation is predicated on proper electrode
in 1871, as a form of vocal nervousness causing hoarse insertion techniques, as briefly outlined here. The CT
speech. In 1973, Aronson further characterized the con­ muscle is located by palpation of the CT space in an
dition into adductor and abductor subtypes, which were extended neck. At a point 0.5 cm from the midline, the
then studied spectographically by Wolfe, Bacon, and electrode is angled 30° laterally and inserted to a depth of
Zwitman in the late 1970s.14,15 In 1981, Cannito and Johnson 1 cm.8 Proper positioning is confirmed by a sharp EMG
attributed the characteristic vocal changes of SD to “spas­ spike with phonation of /i/. To locate the TA muscle, an
modic laryngeal hyperfunction” and “incoordination of electrode is inserted 1–2 cm deep at a point 0.5 cm lateral
vocal fold movement”.16 Shortly thereafter, Finitzo and to the midline at an angle 30–45° superior and lateral
Freeman proposed the existence of a mixed SD subtype (Fig. 1).8 Appropriate insertions into the TA muscle may
after observing patients with features of both adductor also be confirmed with a sharp increase in EMG wave­
forms with phonation of /i/ (Fig. 2). Lastly, insertion into
and abductor dysfunction.6
the PCA muscle requires rotation of the larynx about a
Laryngeal EMG was introduced in 1944 by Weddel et al.,
vertical axis. The electrode is oriented horizontally and
and its techniques were improved by others such as
advanced into the inferior third of the posterior larynx.8
Faaborg-Andersen and Buchtal in the 1950s.9,17 Tarasch et
Alternatively, the airway can be anesthetized and the
al. reported the first experience using LEMG in patients
electrode advanced through the CT space in a superior,
with SD in 1946. The authors found increased laryngeal
lateral direction. The needle tip then pierces posterior
muscle activity in SD compared to healthy controls. Fritz cricoid plate until the PCA muscle is encountered. Given
et al. confirmed the early LEMG findings of SD in 1982 by the PCA muscle’s function as a vocal fold abductor, proper
demonstrating laryngeal spasms in the thyroarytenoid electrode placement is confirmed by EMG activity with
(TA) muscle during phonation. Recurrent laryngeal nerve forceful sniffing. Appropriate electrode placement may
sectioning was advocated as an early treatment for SD; also be confirmed by direct laryngoscopy in all three
however, long-term results were poor.18 Botulinum toxin cases.22
(BTX) injection, the current gold standard of treatment Abnormal LEMG activity is seen in the majority of
for SD, was established in 1987.19 With the advent of less patient with SD, but these changes have not been shown to
invasive treatments, laryngeal EMG evolved as a valuable predict the severity of disease.23 Blitzer et al. demonstrated
diagnostic and therapeutic tool for SD. Since the turn of that the normal delay (0–200 milliseconds) between onset
the 21st century, research focusing on LEMG and SD of electrical and acoustic activity during phonation may
continues to substantiate its use in clinical practice. last up to 1 second in patients with SD.24 Moreover, patients
exhibit intermittent, sudden peaks in muscle activity
corresponding to temporary voice breaks.24 LEMG also
helps distinguish between adductor, abductor, and mixed
Formal guidelines for the diagnosis of SD do not currently dysphonia.25 Kimaid et al. found that all patients with
exist. Many patients are evaluated by a multidisciplinary adductor SD showed increased TA muscle activity at rest
132 Section 2: Clinical Assessment and Office Procedures

Fig. 1: Recording from the right thyroarytenoid muscle at rest in a patient with adductor spasmodic dysphonia. There is persistent firing
of motor unit action potentials (MUAPs). The presence of overlapping MUAPs gives the appearance of increased polyphasia.

Fig. 2: Recording from the right thyroarytenoid muscle of the same patient during phonation (activation). Motor unit action potential
morphology and recruitment pattern, with increased amplitude and frequency, are within expected normal parameters.

on LEMG, in addition to irregular bursts during contraction.11 relief; however, long-term outcomes are poor. Roughly
Similarly, Hillel et al. and Yang et al. demonstrate increased one-third of patients who undergo nerve-sectioning report
latent periods, amplitudes, and frequencies of the TA improvement of symptoms at 3 years postoperation, and only
muscles in patients with adductor SD compared to healthy 3% return to a consistently normal voice.30 Furthermore,
controls.10,26 These patterns suggest that the phonatory these procedures carry the risks of general anesthesia and
breaks and easy fatigability seen clinically in adductor SD invasive surgery.
result from the continuous high intensity, high frequency The current gold standard treatment for SD is injec­
activity of the TA muscle during phonation. In patients with tion and chemodenervation with BTX. Of the various
abductor SD, abnormal PCA acti­vity on LEMG explains forms of BTX in use, onabotulinumtoxin type A (BTX-A)
the clinical symptoms that develop from vocal fold hyper­ is most prevalent.31 Injections may be delivered by a variety
abduction during episodes.11 In practice, these findings of methods such as direct palpation, laryngoscopy or
serve as diagnostic signs of SD that may guide therapeutic LEMG-guidance. Kim et al. investigated the use of LEMG
intervention. versus flexible laryngoscopy for the injection of BTX in
Although there is no cure for SD, advances in treatment patients with adductor SD. Based on a visual analog scale
have lead to increasingly satisfactory results. Syste­mic phar­ from 0 (worst) to 10 (best), the authors found greater
macotherapy provides minimal symptomatic relief in the patient satisfaction following injection with LEMG com­
setting of SD.8 Surgical management has primarily focused pared to flexible laryngoscopy (7.7 versus 6.4; p < 0.05).32
on peripheral muscle denervation with treatments such Trends toward decreased breathiness and days of aspira­
as recurrent laryngeal nerve sectioning or avulsion, TA tion postinjection were also noted with LEMG; however,
myomectomy, and TA denervation and reinnervation.27-29 these results did not reach statistical significance. On aver­
Surgical management may provide signi­ficant short-term age, 90% of patients achieve symptomatic relief following
Chapter 12: Laryngeal Electromyography in Spasmodic Dysphonia and Overview of Spasmodic Dysphonia 133

injection, with effects lasting 3–4 months.33 Complications with LEMG finding may also determined disease prognosis.
of BTX injection typically resolve within the first 2 weeks, In a study of the long-term effects of BTX on LEMG, Mehta
and include breathy dysphonia, minor choking spells, et al. suggest that the effects of treatment may persist
hyperventilation while attempting to phonate against an longer than a few months.40 The authors used LEMG to
abducted glottis, and sore throat.33,34 measure inappropriate muscle activity (IMA) on a 3-point
Laryngeal EMG serves as a guide to BTX injection in scale: little to none; low-amplitude during phonation; and
patients with SD via the use of a specialized hollow needle high-amplitude during phonation. The resulting decrease
electrode.35 LEMG allows greater control over BTX in IMA at 12 and 24 months after repeated BTX injections
injection, and thus better drug delivery into the most active suggests that renervation is a long-term process. Further­
part of the muscle.36 Dosing of BTX varies on a case-by- more, the authors posit that the presence of low-amplitude
case basis as formal guidelines do not exist. In our institu­ IMA at the time of repeat injection may represent minor
tional experience, patients started on a BTX-A dose of 2.5 chemical denervation caused by residual BTX from a pre­
units (U) bilaterally often complain of increased breathi­ vious injection. Given the differential response to BTX,
ness. We found that bilateral injections of 1.25 U of BTX-A treatment should be tailored to each patient to ensure
had a significantly shorter duration of breathiness, without optimal outcomes.
compromising voice outcomes.31 Thus, we recommend
a smaller initial dose of BTX-A with upward titration to NEW HORIZONS
achieve desired voice outcomes in patients with adductor
SD.31 Dose stability over repeated injections is a reflection Neuroimaging studies have recently established a
of the number of previous beneficial injections.37 Current “network model” for dystonic diseases, which suggests that
data do not support a relationship between age and BTX the etiology of SD is multifactorial.41 In addition to the
dose requirement; however, females tend to require more basal ganglia, SD may also involve the cerebral cortex,
BTX than males.38 For patients with adductor SD, BTX is thalamus, cerebellum, brainstem, and white matter tracts.
injected into the TA muscles with potential value gained Furthermore, patients with SD demonstrate abnormali­
from injection into the lateral cricoarytenoids. ties in cortical regions responsible for voice production,
The beneficial effects of BTX typically appear by 6 hours control, and communication, such as the laryngeal senso­
to 2 days and last an average of 15 weeks.39 BTX reaches its rimotor cortex.42,43 Going forward, a better understanding
peak of action 2 weeks after injection, as evidenced by the of SD will allow physicians to identify and manage the
presence of fibrillation potentials and the failure to induce disease more effectively.
evoked potentials on LEMG.10 Yang et al. report that fibril­ Portable, audio-only LEMG machines may provide
lation potentials are a reliable marker of muscle denerva­ physicians with an efficient and safe method for BTX injec­
tion such as with BTX injections. Similar to the findings of tion. Jeffcoat and Schweinfurth report their experience
a completely injured recurrent laryngeal nerve, BTX also using portable LEMG for 113 TA injections in 13 patients
causes nerve evoked potentials to disappear. Because con­ with SD.44 A missed injection was defined as no improve­
duction function decreases in patients with compromised ment in voice quality subjectively or objectively within
nerve function, evoked potential amplitude decreases and 2 weeks following the injection, whereas a successful injec­
signal latency increases. Thus, the absence or reduction tion provided subjective or objective improvement in voice
in evoked potentials on LEMG may suggest the continued quality within 2 weeks and lasted at least 1 month. The
pharmacological effects of BTX. In order to prevent irre­ authors report 13 missed injections using portable LEMG,
versible muscular injury, repeated injections with in the resulting in an 88.5–90.1% successful injection rate. There
setting of abnormal LEMG findings must be approached were no complications following any of the injections.
with caution. Improved surgical techniques have paved the way for
The symptoms and LEMG findings of the SD patients novel treatment strategies for SD. Sanuki et al. describe
tend to return to baseline at approximately 3–4 weeks. As type II thyroplasty with intraoperative voice monitoring to
such, LEMG may be used as a guide to treatment, speci­ guide lateralization of the vocal folds without contact­ing
fically to gauge therapeutic efficacy, timing of next injec­ the laryngeal muscles, nerves, or vocal folds.45 Additionally,
tion, and BTX dosage adjustment. Duration of symptom many authors have described the use of radiofrequency-
improvement following BTX injection, in combination induced thermotherapy (RFITT) for myomectomy.46-48
134 Section 2: Clinical Assessment and Office Procedures

In separate studies, Remacle et al. and Kim et al. report 3. Aronson AE, Brown JR, Litin EM, et al. Spastic dysphonia.
immediate improvement in symptoms with RFITT; how­ I. Voice, neurologic, and psychiatric aspects. J Speech Hear
Disord. 1968;33(3):203-18.
ever, patients tend to return to baseline by 6–12 months.46,47
4. Dedo HH, Townsend JJ, Izdebski K. Current evidence for
Desai et al. describe lasting effects at 6 months using the organic etiology of spastic dysphonia. Otolaryngology.
minithyrotomy to expose the TA muscle for RFITT in a 1978;86(6 Pt 1):ORL-875-80.
sample of mongrel dogs.48 Lastly, Park et al. achieved mean 5. Daraei P, Villari CR, Rubin AD, et al. The role of laryn­
laryngeal adductor pressures 44% of baseline at 6 months goscopy in the diagnosis of spasmodic dysphonia. JAMA
via lateral cricoarytenoid release in a canine larynx model.49 Otolaryngol Head Neck Surg. 2014;140(3):228-32.
6. Finitzo T, Freeman F. Spasmodic dysphonia, whether and
Large human studies will be necessary to validate the where: results of seven years of research. J Speech Hear Res.
preliminary results of these promising new techniques. 1989;32(3):541-55.
7. Tanner K, Roy N, Merrill RM, et al. Spasmodic dyspho­
PEARLS nia: onset, course, socioemotional effects, and treatment
■■ Spasmodic dysphonia is a focal dystonia of the larynx clas­ response. Ann Otol Rhinol Laryngol. 2011;120(7):465-73.
sified into adductor, abductor, and mixed subtypes. Given 8. Sataloff RT. Laryngeal Electromyography, 2nd edition. San
its heterogeneous nature, a tailored approach to treatment Diego, CA: Plural Publishing; 2006. p. 190.
is required on a case-by-case basis. 9. Faaborg-Andersen K, Buchthal F. Action potentials from
■■ Laryngeal EMG, in combination with a thorough clinical internal laryngeal muscles during phonation. Nature.
history, is a valuable tool to evaluate which muscles are 1956;177(4503):340-1.
affected by SD. 10. Yang Q, Xu W, Li Y, et al. Value of laryngeal electromyo­
■■ Adductor SD is the most common variant of the condi­ graphy in spasmodic dysphonia diagnosis and therapy.
tion and exhibits continuous high-intensity and high- Ann Otol Rhinol Laryngol. 2015;124(7):579-83.
frequency activity of the TA muscle during phonation. 11. Kimaid PA, Quagliato EM, Crespo AN, et al. Laryngeal elec­
■■ Laryngeal EMG is a reliable guide to safe and effec­ tromyography in movement disorders: preliminary data.
tive injection of BTX into the laryngeal musculature Arq Neuropsiquiatr. 2004;62(3A):741-4.
of patients with SD. Successful electrode insertion 12. Kotby MN. Percutaneous laryngeal electromyography.
techniques are achieved using appropriate anatomic Standardization of the technique. Folia Phoniatr (Basel).
landmarks. 1975;27(2):116-27.
Beneficial long-term effects of BTX on laryngeal muscula­ 13. Chitkara A, Meyer T, Cultrara A, et al. Dose response of
ture are exhibited by a decrease in IMA on LEMG. topical anesthetic on laryngeal neuromuscular electrical
trans­mission. Ann Otol Rhinol Laryngol. 2005;114(11):819-21.
14. Aronson AE. Psychogenic Voice Disorders: An
CONCLUSION Interdisciplinary Approach to Detection, Diagnosis and
Therapy. Philadelphia: Saunders; 1973. p. 68.
Spasmodic dysphonia is a rare condition with significant 15. Zwitman DH. Bilateral cord dysfunctions: abductor type
impact on patient quality of life. Given the paucity of infor­ spastic dysphonia. J Speech Hear Disord. 1979;44(3):373-8.
mation regarding the etiology of SD, its diagnosis provides 16. Cannito MP, Johnson JP. Spastic dysphonia: a continuum
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Soc Med. 1943;36(10):513-4.
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Going forward, continued research into the etiology of SD dysphonia. Ann Otol Rhinol Laryngol. 1976;85(4 Pt 1):451-9.
and the advent of novel treatment strategies will provide 19. Gacek RR. Botulinum toxin for relief of spasmodic dyspho­
advances in the management of the disease and improved nia. Arch Otolaryngol Head Neck Surg. 1987;113(11):1240.
20. Rodriquez AA, Myers BR, Ford CN. Laryngeal electromy­
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13. Principles and Essentials of Phonomicrosurgery
14. Nodules and Polyps
15. Cysts, Sulci and Mucosal Bridge
16. Lasers in Phonomicrosurgery
17. Lasers in Early Glottic Cancer
18. Principles of Laryngeal Framework Surgery
19. Unilateral Vocal Fold Paralysis and Medialization Laryngoplasty
20. Surgical Treatment of Spasmodic Dysphonia
21. Puberphonia and Relaxation Laryngoplasty
22. Feminizing Laryngoplasty
23. Recurrent Respiratory Papillomatosis and Narrow Band Imaging
24. Glottic Web
25. Considerations in the Professional Voice User
Principles and Essentials
of Phonomicrosurgery

Peter C Baxter, Mark S Courey

INTRODUCTION Removal of the mucosal layer of the vocal fold was thought
to remove diseased tissue and encourage regeneration of
Phonomicrosurgery refers to surgeries performed on the normal healthy mucosal layers. Subsequently, the results
vocal folds at high magnification which are concerned of this technique were unpredictable. Voice quality follow-
with improvement or restoration of voice quality through ing mucosal stripping was often poor particularly when
restoration of vocal fold function or more specifically vocal performed bilaterally.
fold vibration. Special instrumentation and techniques Advances in the understanding of anatomy and phys-
have been developed to preserve the unique layered struc-
iology of the vocal folds led to the discovery of the special
tures of the vocal folds while removing diseased tissue.
layered structure of the vocal fold. Hirano’s cover-body
Earlier forms of vocal fold surgery removed diseased tissue
theory demonstrated that normal vocal fold function was
without magnification and primarily involved mucosal
created by the interaction between the delicate epithe-
stripping techniques. These techniques produced unsat-
lial layer and superficial lamina propria (SLP) over the
isfactory outcomes because the layered structure of the
vocal ligament. Widespread use of laryngeal stroboscopy
vocal fold mucosa was not preserved.
allowed clinics to observe vocal fold vibration created by
The surgical principles in phonomicrosurgery are
the intact layered structure of the mucosa. When the lay-
based on an understanding of vocal fold physiology, which
ered structure was removed injudiciously through surgi-
was elucidated by Hirano’s cover-body theory of vocal
cal “stripping techniques”, stroboscopy allowed the clini-
fold vibration.1 Understanding laryngeal physiology and
cian to appreciate the stiffened nonvibratory nature of the
anatomy is essential to achieving good voice outcomes.
regenerated tissue and to better understand why voice was
Technical considerations and delicate dissection are also
not restore postoperatively. In vocal fold surgery, there-
important in obtaining optimal results. In the future, intro-
fore, stroboscopy has come to serve the same purpose as
duction of regenerative tissues may further improve results
the audiogram has in otologic surgery. In the same way
from phonomicrosurgery.
as an audiogram is a prerequisite to middle ear surgery,
stroboscopy is now a prerequisite to vocal fold surgery.
HISTORICAL CONSIDERATIONS Preservation and restoration of the layered structure of the
Earlier techniques of vocal fold surgery were developed mucosa is understood to be essential in restoring voice.
prior to our understanding of the clinical importance of the To accomplish this goal, contemporary laryngeal sur-
layered structure of the vocal fold. They were often perfor­ geons have developed smaller and more delicate instru-
med without magnification and without an understanding ments than cup forceps and the Loré strippers. In addition,
of the relevance of the mucosa. All surgeons could do was they use magnification similar to or greater than that used
to remove the diseased tissue and/or the lesion with the in ear surgery. Finally, techniques of vocal fold micro-
surrounding mucosa. This was done primarily by grasping dissection have been standardized and shown in clinical
the tissue with a 2−4-mm cup forceps and pulling it off. series to produce reliable vocal outcomes.3-5
This was termed the “mucosal stripping technique” and These microdissection techniques, initially introduced
instruments were developed specifically to strip mucosa.2 originally by Bouchayer,3 were refined and studied by
140 Section 3: Phonosurgery

Figs. 1A and B: (A) Diagrammatic representation of lateral microflap and (B) Diagrammatic representation of medial microflap.

­several authors.3 Through refinement in surgical instru- normal vibration cannot always be restored. In addition,
ments, the use of high magnification, and follow-up of the technique is demanding as the surgeon must operate
clinical results, these microdissection techniques were with arms outstretched leading to physical pain. Chairs
demonstrated to produce reliable results in terms of resto- with arm-support help stabilize the arms and can result in
ration of vocal fold vibration and vocal improvement. They improved techniques and outcomes.
are an improvement to the mucosal stripping and have The medial microflap was developed for use when
become the standard of care for the management of dis- an extensive dissection was not required or when the
ease of the vocal fold mucosa. superficial layer of the lamina propria was diseased just
In attempts to standardize techniques, investigators beneath the basement membrane zone (BMZ). In these
have described them by the position of the initial incision cases, there is no overlying cover to preserve as dissection
on the vocal fold, either lateral or medial4,6 (Figs. 1A and B). within the BMZ is not possible. The overlying epithelium is
or by the size of the tissue to be removed—mini-microflap only 25−50 microns thick. It is not possible to dissect and
resection.5 The lateral microflap begins with an incision preserve a layer this thin. In addition, dissection occurs
made lateral to the lesion on the superior surface of the within the middle of the lamina propria as this is the area
vocal fold. When incising and dissecting in normal vocal of least resistance.7 The BMZ is rich in anchoring filaments
folds, the natural dissection plane occurs within the mid- which are not easily separated through blunt dissection.
dle of the superficial layer of the lamina propria.7 There- Therefore, if the disease is very superficial, vibration on
fore, with extensive disease or when disease within the stroboscopy will be relatively well-preserved. In addition,
lamina propria does not lift easily from the deeper layers during operative palpation of the lesion, it will separate
as occurs with loss of vibration of stroboscopy or during easily from the underlying vocal ligament. An incision
operative palpation, the incision is best made in an area can be made over the lesion. This will allow the surgeon to
free of disease on the dorsal lateral surface of the vocal fold. preserve lamina propria near the lesion while still allow-
The normal layers of the lamina propria can be identified. ing the surgeon to develop a plane between the lesion and
This allows the surgeon to identify the diseased tissue and the underlying vocal ligament. The lesion can be removed
then work superficial and deep to it while sparing under- and bluntly dissected from the inferior aspect of the vocal
lying vocal ligament and overlying, uninvolved cover. In fold.This will allow the creation of an inferiorly based
this manner, the diseased tissue is excised and any normal flap (Fig. 1B) of epithelium and SLP that can be redraped
remaining tissue is then redraped over the defect to allow to approximate the superiorly based flap and lessen any
healing by primary intention. The lateral microflap was an defect that may have been created by removal of the
improvement to mucosal stripping techniques; however, diseased tissue. This will allow intention by primary healing
extensive disease often leads to extensive resection, thus rather than secondary healing with scar contracture.
Chapter 13: Principles and Essentials of Phonomicrosurgery 141

The mini-microflap excision technique is proposed by ■■ Operating microscope with 400-mm lens
some authors when the disease is very superficial. Their ■■ Laryngoscope
thought process is that epithelium readily regenerates ◆◆ Dedo
over the remaining SLP8 and that dissection within the ◆◆ Ossoff-pilling
lamina propria may actually be more traumatic than ◆◆ Lindholm
simple superficial excision.5 These authors advocate care- ◆◆ Hollinger anterior commissure scope
ful dissection and removal of the lesion. This technique ■■ Suspension system
often works well in patients with epithelial disease such ◆◆ Storz suspension
as keratosis or recurrent respiratory papillomatosis. How-
◆◆ Lewy suspension system
ever, if the dissection is unintentionally carried deeply,
■■ Mouth guard
re-epithelization will occur over the remaining lamina
■■ Operating chair with appropriate arm supports
propria and healing by secondary intention can result in
■■ Telescope with associated tower
scar contracture.
Diagram 1: Vocal fold anatomy (refer to Fig. 15 in ◆◆ 0°, 70° Hopkins rod
Chapter 2). ■■ Medications
◆◆ 1:10,000 epinephrine on pledgets
ANATOMY OF THE VOCAL FOLD ◆◆ Injectable steroids
■■ Example of instrument tray (Figs. 2A to E)
The human vocal fold is a layered structure consisting of ◆◆ Sickle blade
the outer epithelial layer, typically less than 25 microns ◆◆ Microcup forceps 1 and 2 mm options
thick. The epithelial layer of the vocal fold is nonkerati- ◆◆ Microscissors
nized stratified squamous epithelium. The epithelial layer
◆◆ Microlaryngeal suctions 3, 5, and 7 French options
is attached to the underlying SLP via the BMZ. The BMZ is
◆◆ Bouchayer forceps
composed of multiple collagen fibers (type 4) with anchor-
◆◆ Alligator forceps both curved and straight.
ing filaments (collagen type 7) connecting the SLP to the
The SLP is a spongy layer comprised of glycoproteins PREOPERATIVE ASSESSMENT
and glycosaminoglycans. These particles are hydrophilic
The surgeon performs a stroboscopic evaluation of the
and control the water content, and therefore, the viscos-
vocal folds. Stroboscopy identifies the part of the vocal
ity of this layer allows it to vibrate freely. The intermediate
and deep layers are difficult to distinguish under binocular fold that is involved and the depth of involvement and
light microscopy. They comprise the vocal ligament. The is paramount to surgical planning. A voice assessment
intermediate layer has a higher concentration of elastin to including voice recording and subjective measurements
collagen. The deeper layer has more collagen. Deep to the is necessary to compare to postoperative results. Patients
lamina propria is the vocalis muscle. The epithelial layer who are candidates for speech language pathology should
and the superficial lamina provide the cover of the vocal be appropriately triaged and treated prior to any surgical
fold. The gelatinous layer of the SLP allows the epithelium intervention. Many lesions will respond to voice therapy,
to vibrate over the ligament; this vibration is modulated by furthermore pathology often results from inappropriate
the vocalis muscle. use and failure to correct poor voice technique will lead to
operative failures.
EQUIPMENT The surgeon must also assess the patient for any
There are numerous available fine instruments and laryngo- medical issues that might impact voice outcome. Ide-
scopes (Figs. 2A to E). Use of instrumentation is operator ally, the patient should be off all blood thinners. Med-
and institutional dependent. These examples provided are ically unstable patients are not suitable candidates for
the preferred instrumentation at our institution and are no elective voice procedures. The oral cavity should be
means an all-inclusive list of instruments. Good exposure inspected for adequate jaw opening and any anatomi-
of the vocal fold is critical to obtaining ideal results; use cal considerations that would make direct laryngoscopy
of precise and reliable instrumentation with appropriate difficult. Prior history of radiation and/or surgery of the
hemostasis is necessary for success. neck is relevant.
142 Section 3: Phonosurgery



Figs. 2A to E: (A) Bouchayer forceps; (B) Microscissors; (C) Alli­

gator forceps; (D) Microcupped forceps; (E) Microflap dissector
E and sickle.

techniques will make exposure difficult or dangerous and

is a setup for disaster. The smallest possible endotracheal
Partnership with an anesthesia team knowledgeable about tube should be selected. Ideally a 5.0-endotracheal tube
phonomicrosurgery is critical. Traumatic intubation, use of should be unitized during intubation. Paralysis is advisa-
the inappropriate endotracheal tube, and poor anesthetic ble; microflap dissection routinely requires 30−40 minutes.
Chapter 13: Principles and Essentials of Phonomicrosurgery 143

If the patient is relaxed at the beginning of the procedure, epiglottis is visualized. The laryngoscope is then advanced
the vocal folds will remain relaxed for the duration of the carefully under the epiglottis above the endotracheal
procedure. Failure to time paralysis appropriately can lead tube until the larynx is visualized. The endoscopist should
to delays in surgery and possible motion at critical times of take care to avoid fulcruming. If anterior exposure of the
the procedure. The senior endoscopist should perform the larynx is difficult the laryngoscope should be elevated in a
intubation. At tertiary institutions trainees are often present superior-anterior direction. This lifts the hyoid anteriorly
who would like to attempt intubation. Often they do not and suspends the larynx. The vocal folds are carefully
understand the importance of atraumatic i­ntubation for inspected, and the lesion should be examined. Once the
our voice patients, and the intubation achieves an unde- endoscopist is certain that adequate exposure can be made
sired surgical outcome. Polyps and cysts can tear or rup- then the laryngoscope should be switched to the largest
ture due to traumatic intubation. A hemorrhagic vocal fold laryngoscope that will ensure adequate and atraumatic
will take longer to recover and will make delicate dissec- exposure. The appropriate laryngoscope is then inserted,
tion impossible. and the patient is carefully placed in suspension. If ade-
If the surgeon is considering the use of a laser, spe- quate exposure is difficult the surgeon should ensure that
cial precautions should be taken. Preparing the patient the patients head is extended and neck is flexed (sniff-
as though you will use the laser for every procedure can ing position). If further exposure is necessary the surgeon
prevent forgetting critical protective measures. A laser safe can further flex the neck by elevating the head of bed
tube should be selected; the cuff should be filled with dyed carefully. Finally tape can be secured over the cricoid car-
saline. The eyes should be taped with moist sponges in tilage to improve anterior exposure. The vast majority of
place and fire-resistant tape. The face and all exposed skin patient’s will be adequately exposed utilizing these methods.
surfaces must be covered with moist towels. The anesthe- An anterior commissure scope can be used if all else fails
siologist must be trained in use of appropriate anesthetics but does not allow binocular visualization of the glottis. The
with the laser. Nitrous anesthetic must not be utilized dur- surgeon must decide if he or she has adequate exposure to
ing the case. Oxygen levels should be titrated to maintain obtain the desired results. The procedure should be aborted
saturations at the lowest possible oxygen concentration. and other options considered if this is not the case.
There are numerous ventilation options for laryngeal
surgery. Endotracheal tube placement is ideal for most
phonomicrosurgical techniques. The use of jet ventilation PROCEDURE
either proximal or distal creates turbulence at the resec-
tion site and leads to increased stress on the anesthesiolo-
Medial Microflap Technique4
gist. Usually, the lesion can be appropriately exposed with Once adequate visualization of the vocal folds is made,
a small endotracheal tube. the surgeon can proceed with the operative procedure.
Failure to take the time to obtain appropriate exposure
EXPOSURE invariably leads to frustration and poor outcomes. The
lesion is next carefully assessed with the 0° telescope, and
The anesthesiologist in conjunction with the laryngologist preoperative pictures are taken. The 30° or 70° telescope
will secure a safe airway with the smallest possible endotra- is next inserted, and the medial surface and ventricle of
cheal tube. The tube should be position in the left lateral the glottis are assessed. It is important to carefully inspect
gutter. The head of bed should be rotated away from the both vocal folds prior to making the incision to make sure
anesthesiologist to give the surgeon ample room for oper- there are not any other lesions that may have been missed
ation. The oral cavity should be carefully inspected and on preoperative assessment.
the dentition should be palpated to ensure that there are Following endoscopic assessment a moistened cotton
no loose teeth. A high-quality tooth guard is placed on the pledget may be placed underneath the vocal folds. This
upper dentition. If the patient is edentulous a moistened helps stabilize the operative site and provides contrast
saline sponge can be carefully placed. If the patient is during the surgery. The vocal folds should be carefully
sufficiently relaxed, the endoscopist can proceed. The palpated using a three French laryngeal suction beginning
smallest laryngoscope (typically anterior commissure with the unaffected side (Fig. 3B). The superficial layer
scope) is carefully inserted into the oral cavity. The laryn- of the vocal fold is gently elevated with the suction and
goscope is advanced along the right gutter until the indicates the depth of involvement of the lesion.
144 Section 3: Phonosurgery

The incision is made with a fresh microlaryngeal sickle particularly if there is a redundancy (Fig. 3G). Draping the
knife over the lateral aspect of the lesion on the medial sur- excess epithelium over the projected defect will deter-
face of the vocal fold. The incision should be made through mine how much epithelium should be resected. Obtain-
the epithelium into the SLP and carried in the vertical ing good edge-to-edge coverage of the mucosal minimizes
plane far enough to ensure adequate exposure (Fig. 3C). scar development. Some surgeons will inject topical ster-
A flap elevator is next inserted into the incision, and the oids into the wound following resection. The flap is gently
flap is raised delicately over the medial-superior portion inspected following resection to ensure the lesion is com-
of the vocal fold lesions. The lesion should be separated pletely removed (Figs. 3A to J).
from the vocal ligament either with blunt dissection or During dissection it is necessary to obtain meticulous
with microscissors or the sickle blade (Fig. 3D). The medial hemostasis. Cottonoids soaked with 1:10,000 ­epinephrine
surface of the lesion should be dissected using blunt dis- are placed on the resection site as needed. After the resec-
section or sharply if necessary (Fig. 3E). Once the lesion tion, an epinephrine-soaked pledget is placed over the
is freed from the epithelial cover and ligament, the lesion resection site for 1−2 minutes. Any remaining cotton-
can be carefully excised using microscissors (Fig. 3F). It is oids should be removed; the count should be confirmed.
sometimes necessary to sacrifice the overlying epithelium Topical lidocaine is placed on the vocal folds to decrease


Figs. 3A to D
Chapter 13: Principles and Essentials of Phonomicrosurgery 145



Figs. 3A to J: (A) Preoperative image; (B) Suction palpation of lesion; (C) Knife incision; (D) Flap elevator creating upper flap; (E) Flap
elevator creating lower flap; (F) Dissecting with two instruments in pocket; (G) Cups grasping flap, trimming flap; (H) Bouchayer on
upper flap; (I) Bouchayer on lower flap; (J) Postoperative image.
146 Section 3: Phonosurgery

the chance of laryngospasm after extubation. Postopera- layered structure of the vocal fold. While these technologies
tive pictures are taken after hemostasis is achieved. The are promising, the benefits have not yet been realized.
laryngoscope is carefully removed; the mouth guard is
removed. The oral cavity is again meticulously inspected CONCLUSION
to ensure no damage to the dentition, no injury to the tem-
Phonomicrosurgery is an attempt to preserve vocal fold
poromandibular joints. The patient is then awoken, and the
function through minimal interruption of the basement
tube should be removed gently avoiding bucking or gagging.
membrane and SLP. Patients receive a thorough voice
assessment preoperatively in conjunction with a speech
POSTOPERATIVE CONSIDERATIONS language pathologist. The laryngologist should work
Postoperative care instructions for voice patients are var- together with an experienced anesthesiologist who is
ied. Most laryngologists agree the patient be on voice rest knowledgeable about voice patients. The laryngologist
for at least 5 days following the operation. Minimizing pho- must have the correct laryngoscopes available for the pro-
nation reduces stress on the surgical site and helps with cedure and the appropriate microlaryngeal instruments.
healing. It is not clear if postoperative medications includ- Appropriate exposure of the glottis is paramount to oper-
ing proton pump inhibitors make a difference in post- ative success along with careful dissection technique and
operative voice outcomes. Oral steroids are not indicated meticulous hemostasis. Minimizing disruption of the SLP
unless significant swelling is anticipated. Pain control is is the key to success. Postoperative voice rest and evalua-
usually achieved with nonnarcotic medications. Depend- tion is necessary to ensure proper healing. Patients should
ing on the exposure time the patient may experience follow up with the speech pathologist and work on adverse
significant tongue discomfort or numbness. Minimizing voice behavior to prevent lesion recurrence.
the duration of suspension is necessary to decrease the
chance of this occurring. A soft diet is appropriate in the REFERENCES
­postoperative period, further dietary restrictions are not 1. Hirano M. Structure and vibratory behavior of the vocal
typically necessary. The patient should follow up within fold. In: Sawashima M, Cooper FS (Eds). Dynamic Aspects
a week of the surgery for postoperative assessment. Vid- of Speech Production. Tokyo, Japan; University of Tokyo
eostroboscopy of the vocal folds is obtained and further Press: 1977. pp. 13-30.
voice and management recommendations can be made 2. Lore JM. Stripping of the vocal cords. Laryngoscope.
at this time. Patients should undergo postoperative voice 3. Bouchayer M, Cornut G. Microsurgery for benign lesions of
therapy to prevent recurrence of their lesions. Patients are the vocal folds. Ear Nose Throat J. 1988;67(6):446-66.
followed closely for 3 months as the majority of healing will 4. Courey MS, Garrett GC, Ossoff RH. Medial microflap
occur by that time. Then at regular intervals for 1−2 years for excision of benign vocal fold lesions. Laryngoscope.
to assure compliance with their new vocal use regimen. 1997;107(3):340-4.
5. Sataloff RT, Spiegal JR, Heurer RJ, et al. Laryngeal mini-mi-
croflap: a new technique and reassessment of the microflap
NEW HORIZONS saga. J Voice. 1995;9(2):198-204.
The future of phonomicrosurgery is regeneration of the nor- 6. Courey MS, Stone RE, Gardner GM, et al. Endoscopic vocal
fold microflap: a three-year experience. Ann Otol Rhinol
mal layers of the vocal folds. There is much work in regen- Laryngol. 1995;104(4 Pt 1):267-73.
erative medicine since Thomson published his paper on 7. Garrett CG, Ossoff RH. Phonomicrosurgery II: surgical tech­
isolation of embryonic stem cells.9 Tissue engineering is a niques. Otolaryngol Clin North Am. 2000;33(4):1063-70.
complicated multidimensional process with the ultimate 8. Toohill RJ, Duncavage JA, Grossman TW. Wound healing in
goal of regenerating healthy tissue layers in affected tissue. the larynx. Otolaryngol Clin North Am. 1984;17(2):4290-36.
9. Thomson JA, Itskovitz-Eldor J, Shapiro SS. Embryonic
If it is not possible to completely restore the vocal folds to stem cell lines derived from human blastocysts. Science.
their prediseased state, it would be preferable to introduce 1998;282(5391):1145-7.
tissue with properties similar to healthy vocal fold layers. 10. Pitman MJ, Rubine SM, Cooper A. Temporalis fascia trans-
There are attempts to place tissue implants above the vocal plant for vocal fold scar and sulcus vocalis. Laryngoscope.
ligament in scar.10 Placement of stem cells and growth fac- 2014;124(7),1653-8.
11. Kanazawa T, Komazawa D, Indo K, et al. Single injec-
tors are also underway.11 In the future, resection of vocal fold tion of basic fibroblast growth factor to treat severe
pathology may be followed with a simple injection of stem vocal fold lesions and vocal fold paralysis. Laryngoscope.
cells or growth factor to decrease scarring and to restore the 2015;125(10):338-44.
Nodules and Polyps

Amitabha Roychoudhury


INTRODUCTION have been found to be screamers, incessant talkers, and
loud talkers.
Vocal fold nodules are benign, small, nodular swellings on Laryngopharyngeal reflux (LPR) has also emerged as a
the medial edge of vocal folds. Classically, they are located major contributory factor to the development of nodules.
at the junction of anterior and middle thirds of vocal fold, Association of nodules and reflux is well documented on
the location being the hallmark feature of nodules. Predi- the basis of ambulatory, three-site pharyngoesophageal
lection of the location is due to phonotrauma at this site of pH monitoring as well as barium esophagography.5 It is
maximum excursion and forceful contact. hypothesized that the baseline inflammation resulting
Nodules commonly occur in children, adolescents, from episodes of LPR adds to the stress of vocal folds
and middle-aged women. In the pediatric age group, the during overuse and misuse.
incidence is higher in boys; on the other hand, in the Preponderance of nodules in patients with congeni­
adults, they are seen more commonly in females with his-
tal anterior commissure microweb has also been docu-
tory of vocal abuse and high professional vocal demand.
mented. Furthermore, nodules associated with microweb
are generally known to be refractory to conservative therapy.6
ETIOLOGY Immunohistochemical studies have confirmed that
fibronectin, a glycoprotein present in the extracellular
Vocal abuse and misuse are the major contributory fac-
matrix, is increased in the SLP of patients suffering from
tors to the development of nodules. Phonotrauma leads to
vocal fold nodules.7 This observation has led to the hypoth-
excessive stress on the mid-membranous vocal fold, causing
esis that some individuals may be genetically predisposed
injury to superficial lamina propria (SLP) and epithelium.
to develop nodules, due to altered molecular activity in
This is followed by tissue remodeling and scarring, resulting extracellular matrix.
in the development of nodules. It has also been noted that Inhalational and nutritional allergens may also con-
an abnormal vibratory pattern may be more damaging than tribute to nodule formation, in synergism to other risk
a high-intensity vibration.1 This explains the higher inci- factors like vocal abuse and reflux.8 In addition, muscle
dence of vocal fold nodules in untrained voice users, com- tension dysphonia or any other hyperfunctional voice dis-
pared to formally trained performing artists. order may contribute to the multifactorial etiology of vocal
Personality trait and psychological factors also play an fold nodules.
important role. It has been documented through Multi­
dimensional Personality Questionnaire2 and Maudsley
Personality Inventory3 studies that patients with vocal PATHOPHYSIOLOGY AND PATHOLOGY
fold nodules are extroverts and show greater social activity, Nodules develop over a period of time. Various stages of
aggression, and impulse.4 Most children with nodules development have been documented. Repeated c­ollision
148 Section 3: Phonosurgery

Figs. 1A and B: (A) Vocal fold nodule. (B) Hourglass glottic closure pattern in early vocal fold nodule.

at mid-membranous portion of the vocal fold leads to typical hourglass phonatory closure, which accounts for
localized vascular congestion and edema. Incessant the breathiness (Fig. 1B). Mucosal waves are generally not
trauma also disrupts and hyalinizes the SLP with conse- impeded, which helps to differentiate nodules from polyps
quent basement membrane zone (BMZ) injury. This leads or cysts, where there is alteration of mucosal waves due to
to epithelial hyperplasia and thickening of BMZ with the involvement of deeper layers of vocal fold.
increased deposition of type IV collagen and fibronec- Nodules usually vary in size, symmetry, contour, and
tin. Continued phonotrauma over the early nodule thus color. Early, young nodules may appear as tiny soft and
formed leads to fibrosis and callus formation in the long pink swellings, whereas more mature, chronic nodules
run, resulting in hard and permanent nodules.9,10 have hard, whitish appearance, being more fibrotic in
Histologically, they are generally acellular with thick- nature.13
ening of epithelium over a matrix with abundant fibrin and
organized collagen.11 The principal histological features of
nodules are epithelial hyperplasia, thickening of basement
membrane, edema, and fibrosis.12 Classical immunohisto- Primary treatment of vocal fold nodules is voice therapy,
chemical features are thickened BMZ rich in fibronectin which should be tailor-made according to the need of each
and more intense fibronectin staining.7 patient. Therapy aims to optimize vocal hygiene, eliminate
behavior-aggravating phonotrauma, and correct mala-
daptive practices.
Voice therapy may be indirect in the form of vocal
AND DIAGNOSIS education and vocal hygiene, where the patient is taught
Patients with vocal fold nodules typically present with var- to phonate in a healthy laryngeal environment in order
ying degree of dysphonia, ranging from hoarse, husky to to optimize voice quality. Educating the patients about
breathy voice. Singers may complain of loss of ability using their pattern of phonotrauma enhances compliance to the
high notes initially, later developing pitch break and vocal treatment.
fatigue.9 History of vocal overuse and misuse is usually Direct voice therapy involves specific exercises to cor-
present in all these patients. rect undue physical colliding forces that lead to nodule
On videostroboscopy, they appear as bilateral, usu- formation. In addition, these exercises are also designed
ally symmetrical, small swellings at the mid-membranous to achieve balance between pulmonary support and vibra-
vocal fold (Fig. 1A). During phonation, the nodules tend tory forces.14 Treatment in individual patients should be
to hug each other, preventing the vocal folds from adduct- planned based on the nature of the nodule and pattern of
ing anterior and posterior to the lesion. This results in the vocal usage of the patient.
Chapter 14: Nodules and Polyps 149

Contributory medical factors such as reflux and allergy Carbon dioxide laser has also been used to success-
should also be appropriately treated. In addition, any psy- fully excise or ablate nodules. The clinical outcome of laser
chological issues should be addressed, where applicable. ablation of nodule is comparable with cold steel surgery.17
It is well documented that voice therapy can lead to res- It is, therefore, the choice of clinician to select the modality
olution of symptoms in 90% of cases.15 However, complete of surgical treatment.
resolution of pathology may not occur in all patients, in Postoperative voice therapy helps maintain a healthy
spite of achieving satisfactory voice quality.14 This usually phonatory behaviour, which plays a crucial role in mini­
happens if the BMZ has undergone irreversible changes. mizing recurrence. Bequignon E, et al. documented
Surgical treatment may be considered in a very small 56% of recurrent dysphonia without postoperative voice
number of patients, whose symptoms and pathology therapy versus 22% with postoperative therapy with a
are refractory to maximal and compliant voice therapy. median follow-up of 9.5 years.16 Furthermore, it has been
Sataloff15 has cautioned that surgery for vocal fold nodules reported that patients treated with an integrated approach
should be avoided whenever possible and should virtually involving both a speech pathologist and otolaryngologist
never be performed without an adequate trial of expert demonstrates greater progress than those who underwent
voice therapy. Microlaryngoscopic excision of nodules isolated voice therapy after surgery and those who under-
may be undertaken, taking care not to expose or damage went therapy alone.18 The author also favours an interac-
the intermediate layer of lamina propria. Precise amputation tive partnership between the laryngologist and the speech
of nodule with preservation of normal mucosa may be and language pathologist through the entire treatment
undertaken, but dissection of the nodule by elevation of a process to attain maximum benefit.
mucosal flap is the preferred method. Initial success rate A Cochrane review in 2012 concluded that there is
after surgery is up to 95%, though recurrence of nodule has paucity of evidence to base reliable conclusions about
been seen in up to 19% of patients in a mean follow-up of comparative effectiveness of surgical versus nonsurgical
5.2 years.16 intervention for vocal fold nodules.19


INTRODUCTION the SLP. Localized edema follows which organizes to a
hyalinized stroma, clinically presenting as polyp.9
Polyps are usually unilateral benign swellings of the vocal It has also been hypothesized, based on histopatho-
folds. They occur more in males, especially between the logical studies, that acute phonotrauma causes increased
ages of 30 years and 40 years.20 vascular permeability which contributes significantly to
polyp formation.
Phonotrauma is the most important etiological factor in
the formation of polyp. Implications of phonotrauma on Vocal fold polyps are generally acellular, with thickened
the vocal fold have been discussed in earlier section of this epithelium over SLP and increased vascularity in an abun-
dant delicate fibrin stromal matrix.21
chapter. On many occasions, acute insult to the vocal fold
Pathologically, they have been categorized into three
can set the stage for polyp formation.
different types: (1) gelatinous, (2) telangiectatic, and
In addition, smoking, reflux, and prolonged use of
(3) transitional, each representing different stages of
anticoagulants predispose to polyp formation in a person
formation of polyps. The edematous stroma and hemor-
with excessive vocal abuse or misuse. rhage of early gelatinous lesions progress through neo-
Another important precursor of polyp, especially in vascularization in telangiectatic polyps and finally to the
professional voice users is varix or capillary ectasia on the fibrinous exudate and hyalinization in late-stage polyps.
vocal fold. Such varices or abnormal dilatation of blood Immunohistochemistry studies demonstrate clustered
vessels usually result from microtrauma. This leads to fibronectin and disruption of laminar pattern, suggesting
neoangiogenesis and subsequent microhaemorrhage in diffuse injury in the region of polyp.7
150 Section 3: Phonosurgery

Fig. 2: Right vocal fold polyp. Fig. 3: Left vocal fold polyp with feeding vessel.


­DIAGNOSIS In general, polyps do not tend to resolve with conservative
Patients with vocal fold polyp typically present with vary- therapy alone, with an exception of a very small number of
ing degrees of hoarseness, pitch break, and loss of range, early polyps. Acute haemorrhagic polyps may show signs of
usually persistent. The degree of dysphonia depends on remission with voice rest and low dose oral corticosteroid.
the mass of the polyp, extent of phonatory gap, and the However, there is a definite role of voice therapy, even if
secondary compensatory behaviors. On rare occasions, surgical treatment is contemplated. Therapy aims to teach
healthy phonatory practice to the individuals along with
extremely large polyps can give rise to breathing difficulty.
correction of compensatory maladaptive behaviours which
On laryngoscopic examination, polyp may appear as
lead to undue supraglottic muscle tension.
sessile or rarely pedunculated swelling on the vocal fold
Most polyps require surgical excision. Surgery aims to
which is clear, white, or reddish, depending on the subcat-
create smooth surface of the vibrating segment of vocal
egory they belong to (Fig. 2). They have also been classified
fold with maximal preservation of epithelium and the lay-
into angiomatous, mucoid, and myxomatous, depend-
ered microarchitecture.
ing on their appearance and content.15 They are usually
In the past, vocal fold polyps have been treated with
attached to the medial, free margin of the vocal fold, but
microlaryngoscopic amputation technique, which can
may be noted along the superior or inferior margins also. result in significant epithelial loss, jeopardizing vocal out-
Polyps are typically unilateral and solitary, though there come. Over the decades, there has been a paradigm shift
may be a “contact lesion” on the contralateral vocal fold towards more conservative, tissue sparing microsurgical
due to prolonged friction. technique. This may be achieved with either cold steel instru-
On videostroboscopy, mucosal waves are found to be ments or laser. Introduction of microflap technique for
normal in 80% of polyps. This helps to differentiate polyps vocal fold surgery in 1980s has revolutionized the pho-
from vocal fold cysts, where mucosal waves are dimi­ natory outcome of benign vocal fold lesions. The original
nished or absent in 100% of cases.22 However, there may concept of microflap was described by Sataloff and his
be aperiodic motion, phase asymmetry, or minor stiffness colleagues.23 The so-called lateral microflap involved tak-
in longstanding polyp, owing to penetration of deeper ing an incision on the superior surface of the vocal fold,
layers of vocal fold. In addition, haemorrhagic polyps may lateral to the lesion. Later, they proposed creating the
also have a prominent feeding vessel running along the incision more medially (medial microflap). In both these
superior surface of vocal fold (Fig. 3). Controversy exists techniques, a mucosal flap was elevated, the mass was
whether these are actually feeding or draining vessels. dissected and excised, keeping the dissection superficial
Chapter 14: Nodules and Polyps 151

microstructure of the vocal folds. With the advent of the

microspot CO2 laser with AcuBlade® feature this apprehen-
sion has reduced remarkably and surgeons are able to use
this kind of laser safely for benign vocal fold lesions with
confidence (Figs. 7A and B).
A large number of polyps have an accompanying
feeding vessel, which usually extends along the ­superior
surface of the vocal fold. Such vessel needs to be attended
to, alongwith polyp resection. These vessels or ectasias
may be effectively vaporized using a pulse dye laser or a
defocussed beam of CO2 laser.26 Laser scores over cold
steel while dealing with such telangiectatic polyps. How-
ever, such vessels may also be resected with cold steel
instruments. This procedure reduces the chance of recur-
Fig. 4: Left vocal fold polyp showing microflap incisions: (1) Lateral, rence of polyp. Zhang et al. reported significantly superior
(2) Medial, (3) Mini. voice recovery with the CO2 laser polyp excision compared
to conventional microsurgery.27 On the other hand, there
are studies concluding that overall postoperative outcome
to vocal ligament. The mucosa was then redraped on to the
is similar with laser and microflap surgery.17,28
vocal fold. However, it had the disadvantage of requiring too
Pulse dye laser has also been successfully used for the
much dissection to reach the lesion, thereby stimulating
treatment of angiomatous polyps, using a combination of
more fibroblastic activity and postoperative scarring. Fur-
the photoangiolytic effect of laser and further dissection
ther concern was raised after the ultrastructural descrip-
and enucleation of the polyp using microflap.29 Office-
tion of BMZ by Gray24 that the epithelium and basement
based procedure of vaporizing small angiomatous polyps
membrane are attached to the superficial layer of the lam-
using angiolytic potassium titanyl phosphate (KTP) laser is
ina propria through an intricate series of type VII collagen
also an emerging technique.30 However, it may necessitate
loops. These loops emanate from and return to basement
repeated procedures and a longer postoperative recovery
membrane cells. Type III collagen fibers of the superfi-
period. Another limitation of office-based intervention is
cial layer of the lamina propria pass through them. It was
constant movement of the larynx in conscious patients,
argued by surgeons that creating a traditional microflap
which may hamper precision.
and unnecessary dissection of the areas not involved by
disease can lead to significant damage to this crucial func- PEARLS
tional unit of BMZ. ■■ Nodules and polyps are the most common benign lesion of
This led to the conceptualization of “mini-microflap” vocal folds.
technique, which was also described by Sataloff.25 In this ■■ Nodules are bilateral small swellings in vocal folds at the
technique, a small mucosal incision is made lateral, yet junction of anterior third and posterior two-thirds.
close to the lesion (Fig. 4). After dissecting superficial to ■■ Polyps are larger swellings on the vocal folds, usually solitary.
■■ Nodules common in children, adolescents, and young
the vocal ligament, the polyp is excised, if necessary, with
females; polyps common in middle-aged men.
its overlying mucosa (Figs. 5A to C). Usually, there is ade- ■■ Multifactorial etiology, voice abuse, and misuse common
quate amount of mucosa to be redraped and even if there for both.
is a small amount of mucosal loss, rapid epithelialization ■■ Both present with varying degree of dysphonia and breath-
takes place (Figs. 6A and B). Limited dissection and keep- iness.
ing the dissection away from the vocal ligament minimizes ■■ Diagnosis by laryngostroboscopy: Mucosal waves normal in
nodule; may be rarely affected in some polyps.
the chances of scarring and therefore does not usually dis-
■■ Majority of nodule respond to voice therapy.
rupt the mucosal wave. ■■ Polyps usually require surgery—microflap or laser equally
Same principle of microflap dissection may be applied, effective.
while using laser. In the past, there has been concern ■■ Pre- and postoperative vocal education and therapy man-
over potential heat distribution of laser on the layered datory.
152 Section 3: Phonosurgery


Figs. 5A to C: (A) Right vocal fold polyp mini-microflap incision.

C (B) Dissection of polyp. (C) Excision of polyp with microscissors.

Figs. 6A and B: (A) Mucosal flap after polypectomy. (B) Mucosal flap after reposition.
Chapter 14: Nodules and Polyps 153

Figs. 7A and B: (A) Right vocal fold polyp. (B) Right vocal fold polyp after CO2 laser excision.

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20. Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol 2015;42(6):453-7.
Rhinol Laryngol. 1982;91(4 Pt 1):378-81. 29. Zeitels SM, Akst LM, Burns JA, et al. Pulsed angiolytic
21. Kotby MN, Nassar AM, Seif EI, et al. Ultrastructural fea- laser treatment of ectasias and varices in singers. Ann Otol
tures of nodules and polyps. Acta Otolaryngol. 1998;105 Rhinol Laryngol. 2006;115(8):571-80.
(5-6):477-82. 30. Wang CT, Huang TW, Liao LJ, et al. Office-based potassium
22. Shohet JA, Courey MS, Scott MA, et al. Value of videostro- titanyl phosphate laser-assisted endoscopic vocal polypec­
boscopic parameters in differentiating true vocal fold cysts tomy. JAMA Otolaryngol Head Neck Surg. 2013;139(6):
from polyps. Laryngoscope. 1996;106:19-26. 610-6.
Cysts, Sulci and Mucosal Bridge

Nupur Kapoor Nerurkar

INTRODUCTION underneath the epithelial layer and is thus referred to as

a SEC. Occasionally this cyst may be adherent to the over-
Subepithelial cysts (SECs), sulci, and mucosal bridges are
lying epithelium, or it may open into the laryngeal lumen
often found in association with one another and thus may
(open cyst), or it may extend into the vocal ligament. This
be labeled as belonging to one family. These lesions are
lesion (vocal fold cyst-ligament) does not respond to voice
all challenging to tackle and may thus be considered as a
difficult family. Surgery followed by speech therapy is the rest or voice therapy, and the prognosis for prompt recov-
accepted management protocol for symptomatic SECs. ery of the voice after surgical excision is less when com-
Complete excision of the cyst wall is mandatory to pre- pared with a vocal fold polyp or subepithelial cyst (SEC).3
vent recurrent cyst formation. The rate of cyst rupture can Glottic SECs may be mucous retention cysts or epi-
be brought down by sharp dissection of the anterior and dermoid cysts. Though these cysts differ histologically
posterior fibrotic bands found tethering almost all cysts, from one another, the treatment for symptomatic patients
likening it (the cyst) to “a pearl on a string”1 (Figs. 1A and B). remains surgical in both cases (Table 1).
Sulci remain a challenging problem even today as post- On occasion, small ovoid subepithelial masses that are
therapy and postsurgery results remain unpredictable. thought preoperatively to be cysts within the SLP are found
Mucosal bridges are difficult to detect even on strobo- at microlaryngoscopy to be fibrous masses. These masses
scopy and their significance and management is fraught are usually firmer to palpation and may be the result of an
with controversy. old microvascular injury or rheumatoid lesion.4
Cysts may be congenital in origin, or a result of pho-
notrauma, and the same is true for sulci and mucosal
bridges. Ruptured cysts may generate vocal fold pits or
mucosal bridges.2 Sulcus has been known since the 19th The lining of a mucous retention cyst is much thinner
century but Bouchayer and Cornut proposed its relation- than that of an epidermoid cyst as it is made up of res-
ship with other vocal fold lesions such as epidermoid cysts piratory epithelium (cuboidal or columnar epithelium)
in the 1980s.2 (Fig. 2). The content of the cyst is typically clear or yel-
This chapter discusses the etiopathogenesis of all low colored fluid (Fig. 3). Mucous retention cysts more
three entities with a discussion of the current management likely result from occlusion of mucous glands on the
protocols. Surgical techniques are described with the inferior surface of the vocal fold.5 This occlusion may be
help of figures. due to phonotrauma resulting in thickened epithelium
The importance of counseling the patient regarding especially near the striking zone of the vocal fold (ante-
postoperative speech therapy, often for long durations, rior one-third, posterior two-thirds junction of the mem-
especially in the case of sulcus, is discussed. branous vocal fold) or due to infection (Fig. 4). Mucous
retention cysts often precipitate the development of
SUBEPITHELIAL CYSTS edema and fibrosis in the surrounding submucosa.6 Due
A cyst is a benign well-encapsulated collection of fluid of to the presence of a thin cyst wall these cysts do have a
varying consistency. In the vocal fold, a cyst is typically higher propensity toward rupturing during surgical exci-
found lying free in the superficial lamina propria (SLP) sion, even in the best of hands.
156 Section 3: Phonosurgery

Figs. 1A and B: (A) Demonstrating a subepithelial cyst with its anterior and posterior fibrotic bands dissected in situ. (B) Demonstrating
the resemblance to a pearl on a string.

Table 1: Comparison between Mucous retention and Epidermoid cysts.

Cyst type Mucous retention Epidermoid
Cyst wall Cuboidal or columnar epithelium Stratified squamous epithelium
Cyst content Liquid Keratin, cholesterol
Etiology Acquired, blocking of duct of mucous gland Congenital cell rests in SLP of remnants of fourth
and sixth branchial arch
Occasionally acquired due to phonotrauma
Size May wax and vane in size Constant in size
Location Often medial vibrating edge or infraglottic Often superior surface of vocal fold.

(SLP: Superficial lamina propria).

Fig. 2: Histopathology of a mucous retention cyst demonstrating Fig. 3: Dissected mucous retention cyst demonstrating the thin
the lining composed of columnar epithelium. wall and clear fluid consistency of the contents.
Chapter 15: Cysts, Sulci and Mucosal Bridge 157

Fig. 4: Mucous retention cyst seen on the medial vibrating edge of Fig. 5: Histopathology of an epidermoid cyst demonstrating the
the right vocal fold at the striking zone. lining composed of stratified squamous epithelium.

Fig. 6: Dissected epidermoid cyst demonstrating the thick wall Fig. 7: Epidermoid cyst seen on the superior surface of the left
and pultaceous consistency of the contents. vocal fold at the striking zone.

EPIDERMOID CYST phonotraumatic fissures developing on the vocal fold epi-

thelium with ingrowth of some epithelium into the SLP,
The lining of an epidermoid retention cyst is much thicker or to be congenital.5 The congenital theory suggests that
than that of a mucous retention cyst as it is made up of epidermoid cysts constitute remnants of the fourth and
stratified squamous epithelium (Fig. 5). The content of sixth branchial arches. Proponents of this theory cite the
the cyst is typically thick, pultaceous, and occasionally longstanding dysphonia that is encountered in patients
cheesy containing keratin and cholesterol debris (Fig. 6). with true vocal cord cysts as evidence for a congenital or
The lesion grows centripetally, frequently eliciting an dysembryoplastic etiology.8 These epidermoid cysts are
inflammatory response in the normal surrounding tissue usually found on the superior surface of the vocal fold at
that consists predominantly of plasma cells and lympho- the striking zone (Fig. 7). Due to the presence of a thick cyst
cytes.2 Epidermoid cysts are sometimes called squamous wall and pultaceous content, these cysts do have a lower
inclusion cysts.7 They are believed to arise either from propensity toward rupturing during surgical excision.
158 Section 3: Phonosurgery

Figs. 8A and B: (A) A strobe image revealing a cyst that appears to be epidermoid in nature on the superior surface of the left vocal fold
with a suspicious vascular contact lesion on the right vocal fold. (B) A narrow band imaging image of the same patient seen in Figure 8A,
where the vascular pattern of the contact lesion on the right vocal fold is seen as the cyan subepithelial veins and a brilliantly white cyst
is seen on the left vocal fold.

Shvero et al. have proposed a new histological classifi- Though narrow band imaging (NBI) has been prima­
cation:9 rily described for vascular lesions, in our experience, small
■■ A: Cysts lined by columnar epithelium with mucous SEC may get picked up on NBI due to the color differen-
content. tiation, with the cyst appearing white against a light blue
■■ B: Lined by columnar epithelium with cilia. backdrop (Fig. 8B).
■■ C: Lined by squamous epithelium without keratini­
■■ D: Lined by squamous epithelium with keratini­
zation. Surgery is the definitive treatment for symptomatic sube-
pithelial cysts.


Patients with a SEC typically have a hoarse voice and over
The mass of the SEC may interfere to a great extent with
time may develop surrounding swelling as well as bad
the amplitude and phase symmetry of the mucosal wave, compensatory techniques. The contralateral vocal fold
depending on its size. Phase asymmetry dominates strobo­ may also develop a contact lesion occasionally. Voice
scopy, given the increased stiffness of the cover and therapy may be of value in breaking any wrong compensa-
common contralateral traumatic changes7 (Fig. 8A). On tory techniques and in decreasing any acute swelling that
phonation, the epithelium often can be seen moving over may be present. The role of postoperative voice therapy
the cyst, so that it appears like an “egg in a soup”.5 It is needs to be explained to the patient preoperatively. Good
common for an hourglass closure pattern to be seen on vocal hygiene, adequate hydration, and reflux manage-
stroboscopy. ment when warranted will always help in optimizing the
The voice of the patient is typically very hoarse, almost healing process and vocal outcomes for the patient.
disproportionate to the apparent size of the glottic lesion. Risks that should be discussed with the patient include
Besides a rough and breathy voice there may also be an the very small possibility (1−2%) that there may be no
increased pitch if coexisting sulci are present. Occasion- improvement and even a worsening of voice quality, and
ally, the patient may be asymptomatic. that surgical outcomes are never 100% predictable.10
Chapter 15: Cysts, Sulci and Mucosal Bridge 159

Figs. 9A and B: (A) Left subepithelial cyst and right contact lesion in Clara-chroma mode of SPIES™ camera; (B) Left subepithelial cyst
and right contact lesion in Spectra A mode of SPIES™ camera.

Phonomicrosurgery is based on the notion that sur- posterior fibrotic bands with the laser. In case the cyst is
gery should be designed to remove the pathology without attached to the ligament, the laser is an extremely efficient
promoting scar formation (i.e. without stimulating fibro- tool in seperating this attachment.
blasts in the intermediate layer of the lamina propria or The surgical steps remain the same for both mucous
deeper).11 retention and epidermoid cysts:
It is important to elevate as little of overlying epithe- ■■ Adequate exposure without excessive tension (stretch-
lium as possible, so as to preserve the delicate architecture ing) of the vocal fold (Figs. 9A and 9B): If necessary
that exists between the interlinked type VII collagen loops, an anterior commissure laryngoscope may be used.
arising from the basement membrane of the epithelium, Ideally, exposure both anterior and posterior to the
with the collagen fibers present in the SLP. This architec- cyst is recommended. If the scope is too close to the
ture was described by Gray et al. in 1994.12 Masses are thus vocal fold, there may be excessive stretching of the
excised with the smallest possible amount of their overly- fold as well as the cyst, making it more susceptible to
ing mucosa, or a mini-microflap is elevated directly over rupture during surgery.
the lesion.13 The plane of the mini-microflap is in the SLP, ■■ Palpation: A blunt flap elevator is reccommended to
deep to the basement membrane, so in theory leaving palpate the lateral extent and infraglottic extension (if
these attachments untouched.14 any) of the cyst. The lateral extension determines the
Surgical excision of the cyst can be performed with placement of the incision (Fig. 10).
cold steel phonomicrosurgical instruments with or with- ■■ Subepithelial infiltration technique (SEIT): Subepithe-
out the aid of a laser. If a laser is used in conjunction with lial infiltration with 1:10,000 saline—adrenaline allows
cold steel instruments then it must have a minimal depth for hydrodissection, hemostasis, temporary mediali­
penetration and should ideally be used in a repeat super- zation, depth penetration estimation and provides a
pulse/ultrapulse mode. The advantage of the laser with heat sink when the laser is being used. A 27 number
a scanner system providing an AcuBlade® is that precise needle is used for this infiltration. The tip of the needle
hemostatic cutting of the anterior and posterior fibrotic should lie just below the epithelium and care should
bands tethering the cyst can be performed. However, tan- be taken to enter lateral enough so that the cyst is not
gential dissection should be performed ideally with cold inadvertently ruptured (Fig. 11).
steel and not with the laser as heat absorption is increased When the cyst is tiny, the SEIT is not recommended as
during tangential dissection. The author prefers to make the cyst in this situation may become more indistinct.
the incision (epithelial cordotomy) following subepithe- ■■ Repeat palpation and incision: Following SEIT the cyst
lial infiltration with the laser and also cut the anterior and is palpated again to confirm lateral extent of the cyst.
160 Section 3: Phonosurgery

Fig. 10: Palpation of infraglottic surface of left vocal fold. Fig. 11: Subepithelial infiltration technique (left vocal fold).

Fig. 12: Left epithelial cordotomy made with the AcuBlade® (red Fig. 13: Elevation of epithelium overlying the cyst with the help of
line). a neurosurgical patty.

An indentation may be made at this point with a blunt prefers to use a CO2 laser with scanner system (AcuB-
flap elevator. The incision is made at the indentation lade®: 10 Watts, 1 mm length, 1 depth, superpulse,
which is immediately lateral to the lateral edge of the repeat) (Fig. 12).
cyst (mini-microflap) such that minimum amount of ■■ Blunt dissection: A blunt dissector attached to a handle
epithelial elevation is needed. This incision may be is used to separate the cyst from the surrounding struc-
made with a sharp sickle knife and extended ante­riorly tures. A neurosurgical patty dipped in 1:10,000 saline
with the same knife or an upward cutting scissors. It is adrenaline is useful for gentle dissection of the epithe-
important to note that the tip of the sickle knife should lium overlying of the cyst (Fig. 13) and the underlying
be used to penetrate the epithelium, and then the tip SLP. This elevation is usually easy unless the cyst is
of the sickle knife can be drawn slightly supe­riorly, attached to the vocal ligament. The laser is extremely
tenting up the epithelium as the incision is made in useful in dissecting cysts from the vocal ligament.
an anterior or posterior direction.3 This incision is ■■ Sharp dissection of the posterior and anterior fibrotic
referred to as an epithelial cordotomy. The author bands (Figs. 14A and B): Almost all cysts will have
Chapter 15: Cysts, Sulci and Mucosal Bridge 161

Figs. 14A and B: (A) Carbon dioxide laser AcuBlade® cutting the posterior fibrotic band; (B) CO2 laser AcuBlade® cutting the anterior
fibrotic band.

Fig. 15: Cyst removal in toto. Fig. 16: Infraglottic flap reposited on medial vibrating edge.

anterior and posterior fibrotic bands. The author refers It is more important to remove the entire cyst wall
to the cyst being tethered by these bands as a “pearl than to preserve epithelial cover as regeneration of
on a string”.1 These bands need to be cut with a sharp epithelium may take time but will take place. However,
scissors or a laser. Once this is done, any remaining unaffected SLP must be preserved as this will not
attachments on the bed need to be dissected allowing regenerate once removed.
the cyst to be delivered in toto (Fig. 15), and the infra- ■■ If the cyst wall is breached during dissection, the area
glottic flap is reposited on the medial vibrating edge of breach may be held with curved crocodile forceps
(Fig. 16). plugging the leak and at the same time providing
■■ Preservation of overlying epithelium: If the cyst is traction medially, thus helping in further dissection.
very large, preservation of the infraglottic epithelium Even if the cyst contents entirely leak out, an attempt
suffices in covering any raw area as there is extra must be made to remove the entire cyst wall, using
redundant epithelium. In the case of small cysts an dissectors or the laser, so as to prevent cyst recurrence
attempt is made to preserve the entire epithelial cover. (Figs. 17 to 25).
162 Section 3: Phonosurgery

Fig. 18: Subepithelial infiltration technique of the right vocal fold

Fig. 17: Right large subepithelial cyst. showing blanching. The needle tip entry is lateral to the cyst.

Fig. 19: Right epithelial cordotomy being performed with an

AcuBlade®. Note the early leak of cyst from the incision site just Fig. 20: Patty being used to separate the cyst from the underlying
above the AcuBlade®. superficial lamina propria.


Pseudocyst has been defined as a discrete, unilateral, Sulcus vocalis is a linear invagination of epithelium along
localized area of Reinke’s edema (without a capsule), the medial edge of the vocal fold into or beyond the super-
usually occurring at the mid-portion of the free-edge ficial layer of the lamina propria. Depth of invagination
striking zone by Kaufmann. In this study by Kaufman and generally correlates with symptom severity, as well as the
Belafsky, it has been recommended that the finding of prognosis for successful treatment.5 Sulci were originally
unilateral Reinke’s edema or pseudocyst should alert the thought to be always congenital with the patient giving a
clinician to the likelihood of vocal cord paresis (paresis classical history of a hoarse voice from childhood. How-
podule).15 ever, cases of sulci developing later on in life, probably due
Chapter 15: Cysts, Sulci and Mucosal Bridge 163

Fig. 21: Decision taken to excise the cyst with overlying epithe­
lium, following its leak, in a bid to remove the cyst wall completely.
The crocodile forceps is holding the cyst away from the underlying Fig. 22: AcuBlade® seen separating the attachments of the cyst
superficial lamina propria. from its bed.

Fig. 23: Leaking cyst almost completely separated from its attach- Fig. 24: Anterior epithelial cut being made after lateralizing the
ments. cyst.

to vocal abuse and misuse or following upper respiratory Garel in 1923 first named the groove “vergeture”,
tract infection (URTI) are not uncommon. Acquired sulci because it resembles the skin disorder of the same name
are often related to poor healing from a vocal fold hemor- (“vergeture” is the French term for stretch mark).17
rhage. It is important to note that an acquired sulcus voca- Bouchayer and Cornut (1985) described two types of
lis is a combination of poor healing skill by the patient, and sulcus: (1) true sulcus corresponding to an open epider-
continued excessive, or sometimes aggressive, voice use moid cyst with thickened epithelium where the bottom of
following injury.16 the cystic pouch is adherent to or transgresses the vocal
In the author’s experience, congenital sulci are typi- ligament, and (2) sulcus vergeture corresponding to atro-
cally deeper with more loss of lamina propria as compared phy of the mucosa covering the vocal ligament.
to acquired phonotraumatic sulci, which are typically less Ford et al. (1996) have described a classification sys-
shallow and often found to be multiple in number. tem for sulcus deformities.18
164 Section 3: Phonosurgery

Historically sulci were thought to be a congenital patho­
logy; however, sulci are often seen to develop following
phonotrauma and also occasionally following URTI. It is
postulated that phonotrauma may result in breaks in the
overlying epithelium of the vocal fold and loss of a variable
amount of SLP. This epithelium heals with the develop-
ment of a sulcus. Another hypothesis is post URTI atrophy
of the vocalis muscle and SLP.
In the author’s opinion, deep sulci are often congenital
in nature and shallow (often multiple) sulci are acquired
and a consequence of phonotrauma (Fig. 28). Sulcus
vocalis can often also have associated vocal fold patho-
logic entities, such as vocal fold lesions (e.g. cysts, fibrous
Fig. 25: Cyst excised completely, raw area seen on right vocal fold. mass, etc.) and mucosal bridges.3
The frequent association between sulci and cysts
cannot be disputed. It has been postulated that a cyst
Type 1 (Physiological Sulcus) may rupture and result in scarring that resembles a
sulcus. Phonotrauma (vocal abuse and misuse) may
A longitudinal depression of the epithelium into the SLP,
be responsible for breaks in epithelium and regenerat-
but not up to the vocal ligament. This depression may
ing epithelium entering these breaks with consequent
extend from the anterior commissure to the vocal process.
sulcus or/and cyst formation. URTI may result in block-
As the depth of invagination of the epithelium in a type 1
ing of the duct of glands resulting in a mucous retention
sulcus is shallow, the patient generally has no voice com-
cyst and may also cause SLP and muscle atrophy result-
plaints, and stroboscopy reveals a normal mucosal wave
ing in sulci.
pattern. Such a sulcus warrants no intervention at all. A
type 1 sulcus is also referred to as a physiological sulcus,
and it is typically picked up incidentally on stroboscopy. VOICE AND VIDEOSTROBOSCOPY
The voice of individuals with a physiological sulcus is nor-
Type 2 (Linear Vergeture/Sulcus mal unless some other pathology coexists.
­Vergeture) On stroboscopy a physiological or type 1 sulcus will
reveal a mucosal wave of normal amplitude and no pho-
A longitudinal depression of the epithelium into the SLP,
natory gap.
reaching up to or going beyond the vocal ligament. This
Shallow sulci result in a phonatory gap that is usually
depression, like the type 1 sulcus, often extends from the
less than 3 mm. The voice is typically rough and breathy,
anterior commissure to the vocal process. A type 2 sulcus
and vocal fatigue and increased effort of speaking are
is also referred to as a linear vergeture (Fig. 26A).
common complaints.
Both unilateral and bilateral linear vergeture usually
On stroboscopy there is mild to moderate decrease in
result in an asymmetric spindle-shaped phonatory gap19
the amplitude of the mucosal wave with aperiodicity and
(Fig. 26B).
Deep sulci extending up to the deep lamina propria or
Type 3 (Focal Pit/Sulcus Vocalis) muscle result in an extremely breathy and hoarse, occa-
A type 3 sulcus refers more to a localized area of depres- sionally high-pitched voice. Air hunger, vocal fatigue, and
sion also called a focal pit. odynophonia are common complaints.
Hyperkeratosis is common near the deepest aspects Stroboscopy reveals a markedly decreased or absent
of the sac or pocket. Some authors believe that this repre- mucosal wave, and the phonatory gap may be greater than
sents an open epidermal cyst20 (Fig. 27). 3 mm.
Chapter 15: Cysts, Sulci and Mucosal Bridge 165

Figs. 26A and B: Bilateral linear vergeture (red arrows).

Fig. 27: Focal pit seen in the left vocal fold with an open cyst within Fig. 28: Multiple superficial sulci on left vocal fold (red arrows) with a
it (red arrow). small hemorrhagic cyst on the superior surface of the right vocal fold.

Pseudosulcus is defined as an apparent groove running
the length of the vocal fold extending into the cartilaginous
vocal fold, this groove represents subglottic swelling, usu-
ally edema21 (Fig. 29).

Though voice therapy does not result in substantive vocal
improvement, it still is the first mainstay of treatment,
especially as postoperative results remain unpredictable.
Not only must the patient of sulcus be counseled regarding
the unpredictable prognosis of postoperative results, the
Fig. 29: Bilateral pseudosulcus (red arrows). worsening of voice in the immediate postoperative month
166 Section 3: Phonosurgery

followed by the need for prolonged and exhaustive voice Liposuction and placing the collected fat in a cen-
therapy needs to be highlighted. There are many surgeries trifuge machine has also been described. The layer of
described for sulcus vocalis, probably because the post- ­adipose cells is used and the layers consisting of blood
operative results of all of these in even very skilled hands and fatty acid cells are discarded. The injection is made
remain limited. with the aid of a high pressure Brunnings syringe or a
The author likes to advice prolonged voice therapy to number 18-scalp vein held with a crocodile forceps. The
patients of sulcus till they themselves are desirous of surgi- needle tip is used to first retract the false vocal fold so as
cal intervention, fully understanding the unpredictability to aid placement in the paraglottic space just anterior
of the postoperative results. to the vocal process. Once the needle is introduced, it is
advanced slightly prior to injection so as to minimize the
extrusion of the fat from the puncture site on withdraw-
An incision is made just lateral to the sulcus; epithelium The vocal outcomes for sulcus by fat injection in the
overlying the sulcus is elevated and repositioned more SLP seem to give better results in younger patients, proba-
medially. The hypothesis of this surgery is that new epithe- bly because of better neuroplasticity of the vocal folds.
lium will grow over the raw area overlying the sulcus.
EXCISION AND SUTURING An attempt to recreate the SLP can be made by placing
An incision is made just lateral to the sulcus; epithelium small pieces of fat in a pocket created by the elevation of
overlying the sulcus is elevated and excised. The new epithelium overlying the sulcus. If the incision made is
edges of the epithelium are sutured to one another or small, it will close off automatically once the fat has been
glued in place. The hypothesis of the surgery is that gutter placed in position. In case a generous incision has been
of the sulcus gets obliterated due to this approximation of made, it should be sutured after the fat has been placed in
the edges (Figs. 30A to E). the pocket (Figs. 31A to E).
Instead of fat, materials such as temporalis facia or
facia lata have also been used. When normal lamina pro-
FAT INJECTION pria reproduction is the goal of implantation, fat is the
Brunnings in 1911 described injection of Teflon using the available material most similar in viscosity [4 Pascal sec-
Brunnings syringe.22 This syringe is still in use in many onds (Pa-s)] to the lamina propria. In contrast, collagen
centers for the injection of fat in the paraglottic space in has a much higher viscosity (10 Pa-s) (Fig. 32).
order to mediatize the vocal fold. Brandenburg et al. pop-
ularized fat injection in 1987. PONTES TECHNIQUE
Autologous fat from the patient’s abdomen or thigh is
Pontes and Behlau introduced a technique involving mul-
prepared to a paste consistency and injected in the para-
tiple incisions throughout the length of the sulcus. These
glottic space (for decreasing the phonatory gap) and into
are multiple relaxing incisions of varying lengths at 90° to
the subepithelial space (to recreate the lamina propria
the sulcus. The hypothesis is that these work as multiple
layer). The fat preparation is time consuming but is of
Z-plasties following established plastic surgery princi-
paramount importance. There are different techniques
ples23 (Fig. 32).
followed for the preparation of the fat. The author pre-
fers to finely chop up pieces of fat which are placed
in insulin so as to support adipocyte cell membrane THYROPLASTY
­stabilization. The fat is then washed in 1−2 liters of When the phonatory gap is more than 3 mm, performing
saline to wash out all the fatty acids. Fatty acids promote a medialization thyroplasty can increase the volume of the
inflammation and should be avoided in the injection voice. Vocal fold augmentation is not as effective at closing
material. The fat is finally squeezed through the nozzle large (3 mm or greater) glottal gaps compared with frame-
of a 2 mm syringe and when it can be squeezed freely it work surgery.3 This can even be performed bilaterally in
is ready for use. mobile vocal folds.
Chapter 15: Cysts, Sulci and Mucosal Bridge 167



Figs. 30A to E: (A) Excision of sulcus vocalis; (B and C) Suturing

the new epithelial edges; (D) Knot slider being used to slide the
knot down to the incision; (E) Sutures in place on both vocal folds
tightly approximating the infraglottic epithelium to the lateral edge
E of the epithelial cordotomy.

GRAY MINITHYROTOMY replacement material.24 The Gray minithyrotomy is

designed for access to subepithelial tissue planes of the
The Gray minithyrotomy is named for Steven Gray, MD, membranous vocal fold via a small skin incision and at
who together with his colleagues developed the ­operation the level of the vocal fold. The minithyrotomy is made
in anticipation of the availability of bioengineered SLP after confirming the level of the vocal fold by a 22 number
168 Section 3: Phonosurgery


Figs. 31A to E: (A) An upward scissors being used to perform an epithelial cordotomy just lateral to the sulcus vocalis; (B) Epi­thelium over
the sulcus being freed by sharp dissection in order to create the pocket; (C) Fat pieces being introduced into the pocket; (D) Suturing
the epithelial edges to seal off the fat-containing pocket; (E) Three sutures taken to close the fat-containing pocket.

needle inserted at the level of the anterior commissure

and confirmed endoscopically. The minithyrotomy is
centered 3−5 mm off the midline at the level of the vocal
fold and a powered 3 mm cutting burr is used to create a
tunnel, which is oriented to the long axis of the vocal fold.
A strip of fat is then gently introduced into the subepithe-
lial space via this tunnel.


Shallow sulci may be aided by injecting material such as
hyaluronic acid in the paraglottic space and in the SLP
(refer to Chapter 10: “Injection Laryngoplasty”).

A mucosal bridge is an epithelial strip lying free over the
vocal fold epithelium, attached only anteriorly and pos-
teriorly (Fig. 33) Occasionally, the mucosal bridge may be
Fig. 32: Pontes and Behlau technique.
thick and muscular.
Chapter 15: Cysts, Sulci and Mucosal Bridge 169

According to the theory of Bouchayer and Cornut and epithelial so as to avoid having two epithelial surfaces
(1985),2 a mucosal bridge arises from two apertures in a vibrating as separate entities during phonation. However,
single epidermoid cyst: (1) superior and (2) inferior, since in the authors opinion,thick muscular mucosal bridges
the mucosal bridge between the two apertures is always are best not removed for fear of decreasing the bulk of the
thick and hyperkeratotic. Some of them could develop vocal fold significantly.
from vocal fold microtrauma.25
Whenever two linear sulci are observed on strobos-
copy (Figs. 34A and B) or during microlaryngeal surgery, NEW HORIZONS
a mucosal bridge should also be looked for. When the Technology is advancing rapidly in all spheres of medi-
patient is under anesthesia, a blunt flat elevator may be cine. In not too distant a future we may be operating on
used to confirm the presence of the mucosal bridge. lesions such as cysts under optical coherence tomography
There exists a dichotomy of opinion among laryngolo- (OCT) control with the aid of robots and advanced lasers.
gists as to the necessity to excise this mucosal bridge or let Bioengineered SLP would probably be the way forward
it remain. The author believes in its excision when it is thin for sulci and scars. Further research is warranted to set
stan­dardized protocols in the management of mucosal

■■ Find the anterior and posterior fibrotic bands tethering the
cyst (pearl on a string) and cut these with a scissors or use
a laser.
■■ If the cyst opens during dissection, plug the leak if possible
by holding it with a curved crocodile forceps and remove
the entire cyst wall.
■■ Overlying epithelium may be sacrificed if the cyst wall
attachment to this epithelium cannot be clearly excised.
■■ Cysts attached to the vocal ligament are best excised using
a laser.
■■ Give exhaustive voice therapy preoperatively and guarded
prognosis regarding vocal outcomes postoperatively in sulci.
■■ Mucosal bridges are best picked up during microlaryngeal
Fig. 33: Left mucosal bridge. surgery.

Figs. 34A and B: (A) Two parallel sulci (red asterisk) seen on the left vocal fold; (B) Mucosal bridge seen overlying these sulci.
170 Section 3: Phonosurgery

CONCLUSION 12. Gray SD, Pignatari SS, Harding P. Morphologic ultrastruc-

ture of anchoring fibers in normal vocal fold basement
Cysts, sulci, and mucosal bridge seem to belong to the same membrane zone. J Voice. 1994;8(1):48-52.
family as they are often seen together in various combina- 13. Sataloff RT, Spiegel JR, Heuer RJ. Laryngeal mini-microflap:
a new technique and reassesment of the microflap saga. J
tions. An accurate diagnosis is essential and the results of
Voice. 1995;9(2):198-204.
surgery for cysts, though not immediate, are rewarding. 14. Choudhury N, Ghufoor K. Benign lesions of the larynx. In:
Patients with cysts and especially those with sulci have to Bhattacharya AK, Nerurkar NK. Laryngology (Otorhino­
be counseled regarding the role of an extended duration of laryngology, Head and Neck Surgery Series). Delhi: Thieme;
speech therapy. Patients of sulci undergoing surgery must 2013. pp. 214-22.
15. Koufman JA, Belafsky PC. Unilateral or localized Reinke’s
be given a realistic and guarded prognosis regarding the
edema (pseudocyst) as a manifestation of vocal fold paresis:
improvement in the vocal outcome. the paresis podule. Laryngoscope. [online] Available from [Accessed
REFERENCES Nov, 2016].
16. Carrol LM. Chapter 18: Voice therapy. In: Fried MP, Tan-
1. Nerurkar N, Shukla S. Subepithelial vocal fold cysts: a pearl Geller M (Eds). Clinical Laryngology: The Essentials.
on a string? Int J Laryngol Phonosurg. 2012;2(2):53-6. Stuttgart: Thieme; 2014. pp. 183-189.
2. Bouchayer M, Cornut G, Witzig E, et al. Epidermoid cysts, 17. Remacle M, Hantzakos A, Matar N, et al. Chapter 8: Laser
sulci and mucosal bridges of the true vocal cord: a report surgery for common laryngeal pathology. In: Oswal V,
of 157 cases. Laryngoscope. 1985;95(9 Pt 1):1087-94. Remacle M (Eds). Principles and Practice of Lasers in
3. Rosen CA, Simpson CB. Chapter 4: Pathological conditions Otorhinolaryngology and Head and Neck Surgery, 2nd
of the vocal fold. Operative Techniques in Laryngology, Vol. edition. Amsterdam: Kugler Publications; 2014. pp. 117-31.
1. Berlin, Heidelberg: Springer; 2008. pp. 21-8. 18. Ford CN, Inagi K, Khidr A, et al. Sulcus vocalis: a rational
4. Zeitels SM. Chapter 7: Benign lesions of the vocal folds. analytical approach to diagnosis and management. Ann
In: Fried MP, Tan-Geller M (Eds). Clinical Laryngology: The Otol Rhinol Laryngol. 1996;105:189-200.
Essentials. Stuttgart: Thieme; 2014. pp. 56-73. 19. Nerurkar N, Gupta H, Shedge A. Diagnostic challenge
5. Franco RA, Andrus JG. Common diagnosis and treatments of sulcus vocalis made easier. Int J Phonosurg Laryngol.
in professional voice users. Otolaryngol Clin North Am. 2015;5(2):39-41.
2007;40(5):1025-61. 20. Sataloff R, Chowdhury F. Chapter 22: Sulcus vocalis. Atlas of
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yps. In: Ossoff RH, Shapshay SM, Woodson GE, Netterville Medical Publishers (P) Ltd.; 2011. pp. 130-2.
JL (Eds). The Larynx. Philadelphia: Lippincott Williams & 21. Timothy D, Anderson MD. Chapter 24: Benign lesions of
Wilkins; 2003. pp. 185-201. the larynx. In: Merati AL, Bielamowicz SA (Eds). Textbook
7. Rubin JS, Yanagisawa E. Benign vocal fold pathology of Laryngology. San Diego, CA: Plural Publishing, Inc.;
through the eyes of the laryngologist. In: Rubin JS, Sataloff 2006. pp. 303-22.
RT, Korovin GS (Eds). Diagnosis and Treatment of Voice 22. Brunnings W. Uber eine neue Behandlungsmethode der
Disorders, 3rd edition. San Diego, CA: Plural Publishing Rekurrenslahmung. Verhandl Ver Dtsch Laryngol. 1911;18:
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8. Monday LA, Cornut G, Bouchayer M, et al. Epidermoid cysts 23. Pontes P, Behlau M. Treatment of sulcus vocalis. Auditory,
of vocal chords. Ann Otol Rhinol Laryngol. 1983;92:124-7. perceptual and acoustic analysis of the slicing mucous sur-
9. Shvero J, Koren R, Hadar T, et al. Clinicopathologic study gical technique. J Voice. 1993;7(4):365-76.
and classification of vocal chord cysts. Pathol Res Pract. 24. Rosen CA, Simpson CB. Chapter 48: The Gray minithyrot-
2000;196(2):95-8. omy for vocal fold scar/sulcus vocalis. Operative Techniques
10. Jamal N, Berke G. Chapter 17: Principles of phonosurgery. in Laryngology, Vol. 2. Berlin, Heidelberg: Springer; 2008.
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Essentials. Stuttgart: Thieme; 2014. pp. 168-82. 25. Man LX, Statham MM, Rosen CA. Mucosal bridge and pit-
11. Sataloff RT, Hawkshaw MJ, Divi V, et al. Voice surgery. ting of the true vocal fold: an unusual complication of cido-
Otolaryngol Clin North Am. 2007;40(5):1151-83. fovir injection. Ann Otol Rhinol Laryngol. 2010;119(4):236-8.
Lasers in Phonomicrosurgery

Nupur Kapoor Nerurkar, Shalaka N Dighe


Phonosurgery encompasses a variety of operations per- ­TECHNIQUE AND MINI-MICROFLAP
formed to restore, improve, or alter a person’s voice. A ­DISSECTION
greater understanding of the microarchitecture of the Infiltration of 1−2 cc of 1:10,000 saline adrenaline into the
vocal folds, invention of the operating microscope, sus- subepithelial space prior to the incision increases the vol-
pension laryngoscopes, and microsurgical instruments ume of the SLP temporarily, helps achieve hemostasis,
led to the development of the new subspeciality of pho- hydrodissection and acts as a heat sink in laser surgeries.4
nomicrosurgery. Hydrodissection takes place with elevation of the lesion
Phonomicrosurgery entails endoscopic vocal fold away from the vocal ligament, when the lesion does not
surgeries using a microscope for magnification of the involve the ligament. An absence of this elevation with
endolarynx. The key principle of these techniques is min- accumulation of the infiltrate around the lesion (doughnut
imal disruption of the multilayered microarchitecture of effect)5 is suggestive of the lesion involving the ligament.
the vocal fold while removing the dysphonia-producing The authors perform subepithelial infiltration technique
pathology.1 This allows healing by primary intention and (SEIT) in most cases, except in very small lesions where
optimal postoperative voice quality. the infiltration may obscure the lesion or when excess SLP
As described by Hirano,2 the vocal folds have a unique is the pathology such as in Reinke’s edema.
multilayered structure comprising: The mini-microflap technique was proposed by
■■ Cover [epithelium and superficial lamina propria Sataloff3 in 1995 wherein the incision is made on the
(SLP)]. The epithelium is secured to the lamina propria lesion itself or as close to the lesion as possible. This
via anchoring filaments of the basement membrane allows for minimal disruption of the anchoring fibrils.
zone (BMZ). Good surgical outcomes can be obtained from cold
■■ Transition zone (vocal ligament—made of intermedi- surgery, laser surgery, or a combination of the two. However,
ate and deep lamina propria) and lasers with a scanning system and an AcuBlade® techno­
■■ Body (thyroarytenoid muscle). logy, when used in experienced hands, do provide certain
A majority of the benign vocal fold lesions arise in inherent advantages when compared to cold surgery in the
the “cover”. It is important to elevate as little epithelium larynx. Lasers coupled to the microscope offer an unob-
as possible during dissection, as even though epithelium structed view of the operation field as the surgeon’s hands
regenerates with time, the anchoring fibrils do not rees- and the instruments do not hamper the field of vision.
tablish their unique architecture. The SLP is vital for the There is minimal tissue manipulation and better hemosta-
production of the mucosal wave and has a poor propensity sis and precision. However, the use of lasers requires strict
toward regeneration, thus must be maximally preserved. adherence to laser safety protocols and proper training of
One must avoid trauma to the vocal ligament, as this leads the medical staff to ensure effectiveness and safety. There
to proliferation of fibroblasts and subsequent scarring. A is also a significant cost associated with the installation
combination of the subepithelial infiltration technique of the equipment; maintenance and updating technical
with the mini-microflap technique3 helps to carry out the developments can be significantly more costly than using
dissection in accordance with these principles. cold instruments.6
172 Section 3: Phonosurgery

There is a definite learning curve associated with the 1. Brilliancy: The laser beam is extremely intense.
use of laser and an excellent microlaryngeal laser surgeon 2. Coherence: All the emitted photons vibrate in-phase,
must be trained as an excellent microlaryngeal surgeon both in space and in time.
first. 3. High collimation: All the photons travel in one direc-
As is rightly said, “No surgical technique is any better tion with minimum dissipation of energy. This allows
than the individual using it”. the emission of an extremely narrow beam, which can
be focused on a very small spot size.
4. Monochromaticity: The emitted light has only one
HISTORICAL ASPECTS wavelength. This allows precise targeting of chromo-
Albert Einstein laid the foundation for the development of phores while sparing the surrounding tissues.
laser when he proposed the concept of stimulated emis- When electromagnetic energy (incident radiation)
sion7 in a paper on quantum theory of radiation in 1917. It falls on the tissue, the tissue reflects part, absorbs part,
took almost 40 years to use his idea and find the right kind and transmits and scatters part of the light. The biological
of atoms and to add reflecting mirrors to help the stimu- effects of the laser are exerted only by the absorbed part
lated emission along, and thus, invent the laser. The first of radiation. Absorbed photons then produce thermal,
working laser was the “Ruby laser” built in 1960 by The- mechanical, or chemical changes in the target tissue.
odore Maimon at Hughes Research Laboratory using a Let us now define measurements that are routinely
Ruby crystal.8 There was immense interest in the medical used in laser applications.
application of laser. However, difficulty in controlling the Energy is proportional to the number of photons emit-
power output, delivery of laser, and poor tissue absorption ted and is measured in Joules. Power is the rate at which
led to disappointing results. energy is delivered by the laser beam. It is measured in
watts (W), where 1 W = 1 J/s.
Shortly afterwards, in 1964 C Kumar Patel devel-
Irradiance is the power per unit area and is measured
oped the CO2 (carbon dioxide) laser at Bell Laboratories.9
in W/cm2.
Researchers found that CO2 laser was very well absorbed
Fluence is:
by soft tissues and could cut like a scalpel with minimum
Power × Time
blood loss. CO2 laser was first applied successfully in 1967 Irradiance × Time =
Spot size
by Jako and Polyani on cadaveric larynges.10 In 1968, Bre-
Fluence is measured in J/cm . 2
demeier developed an endoscopic laser delivery system,11
In 1983, Anderson and Parrish13 described the theory
following which, Jako first used the CO2 laser in vivo on a
of selective photothermolysis, which revolutionized laser
canine model.10,12 Bredemeier’s invention of the micro-
therapy by explaining a method of producing localized
manipulator allowed the delivery of CO2 energy through a tissue damage sparing the surrounding tissues. For under-
microscope and this paved the way for the current micro- standing this we need to understand certain terms.
laryngeal laser surgery era. ■■ Threshold fluence of a tissue is a fluence, which if
equaled or exceeded leads to the tissue destruction.
LASER PHYSICS ■■ Thermal relaxation time (TRT) is defined as the time
required by an object to cool down to 50% of the initial
Laser is an acronym for light amplification by stimulated temperature achieved.
emission of radiation. For tissue damage to ensue, a wavelength should be
The atoms of a laser exist within a medium, which preferentially absorbed by the chromophore (e.g. oxy-
can be either solid, liquid, or gas. This is encased within hemoglobin, water, melanin) in the target tissue and not
an optical resonant chamber in-between two mirrors. The absorbed by the surrounding tissue. Maximum absorp-
process of laser emission begins with an external source tion occurs when the wavelength of the laser matches the
of energy, such as a flash lamp or an electric arc, which absorption coefficient of the target chromophore.
is used to excite the atoms in the medium. The internal The energy needs to be delivered in a pulse duration
energy contributes to a cascade of stimulated emissions which is less than or equal to the TRT of the target. If deliv-
that create the amplified light energy. ery time exceeds the TRT then the target does not get dam-
A laser beam has four fundamental characteristics, aged, instead the energy dissipates to the surrounding tis-
which differentiate it from ordinary light: sues inflicting injury there. Even if energy delivery occurs
Chapter 16: Lasers in Phonomicrosurgery 173

within the TRT limits, the fluence reaching the target after
subtracting reflection and scattering in the path needs
to equal or exceed the threshold fluence to cause tissue
destruction.14 Thus, selective photothermolysis can be
achieved by manipulating two variables: (1) wavelength
and (2) fluence.
The most common type of lasers used in laryngology
are CO2 laser (10,600 nm), potassium titanyl phosphate
(KTP) laser (532 nm), dye laser (585 nm), and neodym-
ium-doped yttrium aluminum garnet (Nd:YAG) laser
(1,064 nm). Each type of laser exhibits characteristic and
different biological effects on tissue and is therefore useful
for different applications.

CO2 Laser Fig. 1: Modes of operation of CO2 laser—continuous wave and

It is the undisputed workhorse in laryngology and when pulsed mode.
only one laser can be purchased for use, the CO2 laser is
recommended. Its wavelength of 10,600 nm is in the far
Superpulse and ultrapulse laser have a high pulse
infrared and has a high coefficient of absorption for water
power and short pulse width. Hence, they reach the abla-
(dominant content of soft tissues). Soft tissues therefore
tion threshold well within the TRT, resulting in mini-
strongly absorb energy from the CO2 laser, limiting collat-
mum, controlled collateral thermal damage. Superpulse is
eral thermal damage to a range of micrometers, if the laser
is only applied to the tissue for brief microsecond periods cone-shaped and its rising and falling parts are below the
by pulsing the laser output.15 ablation threshold (Fig. 1). Ultrapulse is rectangular and
This ability to ablate and cut the water-rich soft tissue its pulse energy is always above the ablation threshold,
with maximum precision and minimal collateral thermal resulting in the cleanest and neatest cut with least thermal
damage makes it a true “what you see is what you get” sur- damage. However, this difference is perceptible only dur-
gical laser. ing surgery. The quality of healing and the postoperative
vocal fold vibration are similar.16
AcuSpot® Micromanipulator,
The last decade has witnessed tremendous technological
advances, which have added incredible precision to CO2
Scanner, AcuBlade®
laser microsurgery with minimal thermal damage. The AcuSpot® scanning micromanipulator creates the
smallest possible beam diameter available to date (250 µm
Superpulse and Ultrapulse Modes for a focal length of 400 mm).
The scanner is a device connected between the laser
The early continuous wave (CW) CO2 lasers caused signif-
icant collateral thermal damage surrounding the incision arm and micromanipulator, which allows the laser beam
and hence, their use in benign laryngeal lesions was not to scan a given surface with extreme rapidity and this
advocated. This led to the development of superpulse and beam scanning the surface is referred to as the AcuBlade®.
ultrapulse modes of operation. The AcuBlade® scanner software modification allows
Thermal relaxation time of CO2 laser-heated tissue the beam to travel across the target as a straight or curved
is about 0.8 ms. If the ablation threshold, 100°C, is not line. The length of incision (0.5–3.5 mm) and the depth of
reached under TRT, this part of the energy goes into the penetration (0.2–2 mm) are programmable. The incision
surrounding tissues and thermal damage and charring line can be rotated to the right or left using the joystick.
occurs. CW lasers provide a low power, constant pulse of The surgeon must have a thorough understanding
long duration. This results in a wide, uncontrolled zone of of laser physics and settings (power + spot size + on/off
thermal damage. period = fluence) for proper and successful use of the laser.
174 Section 3: Phonosurgery

As the scanning system allows for the laser spot to ■■ Use of saline-soaked subglottis (SG) cottonoid for pro-
quickly “scan” a surface area, which may be a straight/ tecting the cuff from the laser beam.
curved line or circle, thus the heat dissipated at any one ■■ The oxygen concentration (FiO2) should be kept as low
point is minimal and this allows for greater power (watts) as clinically feasible, usually under 25%. Oxygen con-
to be used with minimal char formation and optimal cut- centration is reduced by dilution with atmospheric air.
ting. The optimal time on/off and recommended power Nitrous oxide should be avoided as it supports com-
are often determined by the laser machine being used, and bustion.
each machine has its own predetermined optimal fluence. ■■ Limit the laser output to the lowest clinically accept-
The continuous mode is not recommended in pho- able power output and pulse duration.
nomicrosurgery as it does not allow for adequate cooling ■■ Test fire the laser before starting the procedure.
of tissues. The first author typically prefers using the Acu­ Lasers should always be set to the “standby” mode,
Blade® in repeat superpulse mode with 10 W energy with a except when they are ready to fire, so that inadvertent
1−2 mm straight AcuBlade® with a 1−2 depth (1 = 250 μm) actuation is impossible.
and a time on/off as 0.03 ms/0.3 ms. Variations in settings A bucket of water must be kept close by to extinguish
do occasionally take place on a case-by-case basis. an inadvertent airway fire.
In keeping with the doctrine of “Primum non nocere” Effective suction should always be employed for evacua­
(first do no harm), we feel that one must use the AcuBlade® tion of the laser plumes in order to allow unhampered
with superpulse or ultrapulse modes for benign vocal fold surgery, to prevent the entry of smoke and plumes into the
lesions. patient’s distal airway and to prevent possible viral infec-
tion to the surgeon and OT personnel in cases such as
respiratory papillomatosis.
A warning sign should be put up outside the operating SPECIFIC CONSIDERATION OF VARIOUS
room (OR) saying that a laser surgery is in progress and
entry and exit should be restricted to required personnel.
Vocal Fold Polyp
Protection of OR Personnel
Vocal fold polyps present as sessile or pedunculated
All OR personnel must wear protective eyeglasses with masses involving the free edge of the vocal fold (Fig. 2A).
side protectors. Wavelength-specific protective eyeglasses These are typically unilateral but often have a contact
(usually tinted) must be worn when working with Nd:YAG, lesion on the contralateral vocal fold. These usually arise
argon, pulse dye laser (PDL), and KTP laser. due to vocal misuse or overuse.
The mucosa overlying the polyp is usually thin and
Patient Protection atrophic and not suitable for preservation.1 However, pres-
ervation of the often stretched infraglottic epithelium is
Patient’s eyes must be protected with saline-moistened
vital, as this, then drapes the medial vibrating edge. The
eye pads or special glasses provided for the patient. The
polyp is gently held, preferably with a Bouchayer forceps,
patient’s face is covered with wet surgical towels.
and an incision is made just lateral to the polyp following
subepithelial infiltration (Fig. 2B). A flap elevator is used
Airway Protection
to dissect the polyp from the epithelium and the underly-
Airway fire remains the most dreaded complication of ing SLP. The epithelium lying on the undersurface of the
laryngeal laser surgery. Laser-resistant tubes do not pro- vocal fold (infraglottic) near the medial edge needs to be
vide 100% protection against endotracheal tube (ETT) elevated during this process and is useful in redraping the
fires. The tube cuff is the the inflammable part of the ETT. medial vibrating edge of the vocal fold. The polyp can now
This necessitates the use of additional safety measures like be excised with the use of the AcuBlade® in superpulse/
■■ Saline-filled cuffs: Proximal cuff should be filled with ultrapulse mode with extreme precision (Fig. 2C). In case
methylene blue + saline for easier detection of possible of very large polyps, there is a lot of redundant mucosa,
perforation. which has to be trimmed. The infraglottic epithelium
Chapter 16: Lasers in Phonomicrosurgery 175


Figs. 2A to D: (A) Right hemorrhagic polyp; (B) Epithelial cordotomy done with laser; (C) Mini-microflap excision of the polyp; (D) Post-
operative view.

is preserved and carefully draped back after excision of sequelae of vocal fold hemorrhage and laryngitis are com-
the polyp. The vocal fold is then examined and palpated mon in professional voice users.17
carefully to look for any residual abnormal lesion. At the There is no widely accepted nomenclature for the vas-
end of the surgery, the free edge of each vocal fold should cular lesions of the vocal folds. Hochman et al. proposed
be completely straight, without any exophytic mucosal the following classification18 (Fig. 3A):
tags and without a divot or concavity of the free edge at the ■■ Varix: Varix is a prominent, dilated, and commonly
surgical site1 (Fig. 2D). tortuous vein.
Lasers have an edge over cold steel in the case of hemor- ■■ Ectasia: These have a coalescent hemangiomatous
rhagic polyps as these are usually associated with a feeding appearance.
vessel. The CO2 laser can be used in a defocused mode to ■■ Spider telangiectasia: It is a delicate network of blood
coagulate the feeding vessels up to a diameter of 0.5 mm. vessels.
The clinical picture is highly variable. The patient may
Vocal Fold Vascular Lesions be entirely asymptomatic or may have subtle symptoms
The vocal fold blood vessels are delicate and are subjected such as vocal fatigue or decreased vocal range, especially
to high-pressure shearing movement during phonation. in professional voice users. Lesions on the medial vibra-
As a result, microvascular lesions and their associated tory edge of the vocal fold can cause dysphonia due to mass
176 Section 3: Phonosurgery

effect and disruption of the mucosal wave. Severe dyspho- Carbon dioxide laser is used in a defocused mode at
nia may result from acute subepithelial hemorrhage. low power setting (1−2 W) to coagulate the offending
Irrespective of the varied nomenclature and clinical vessel at 2 or 3 different spots (Fig. 3C). Alternatively,
presentation, the management protocol remains the same. photoangiolytic lasers such as PDL and KTP can be used in
In case of acute subepithelial hemorrhage, the patient an outpatient setting.
must be advised strict voice rest for 7 days, a course of oral
steroids with due precautions, cessation of anticoagulant Subepithelial Vocal Fold Cyst
medication (if possible), and avoidance of nonsteroidal A subepithelial vocal fold cyst (SEVFC) is a well-demar-
anti-inflammatory drugs. In case of persistent subepithelial cated, epithelium-lined sac-like structure within the
hemorrhage, an incision is made on the superior surface lamina propria (Fig. 4A). It is always preferable to avoid
of the vocal fold laterally and the blood is evacuated. No rupture of the cyst during dissection, as this may result in
attempt should be made to lase the submucosal bleed, as incomplete cyst wall resection and subsequent recurrence.
this can result in significant scarring. However, cysts do rupture occasionally even in the best of
Surgery is recommended in case of recurrent hemor- hands, especially in case of thin-walled mucous retention
rhage, development of an associated mass such as cyst or cysts. It is important to make all attempts to remove the
polyp (Fig. 3B), or significant dysphonia. In addition, sur- entire cyst wall even when the cyst ruptures in order to
gery may be required for evacuation of the hematoma in prevent recurrence. The laser is very useful in such a situa-
case of failure of conservative treatment. tion to laser ablate any suspicious residual tissue.


Figs. 3A to C: (A) Left vocal fold vascular lesions with an asso-

ciated polyp. Blue arrow—varix; yellow arrow—ectasia; (B) Polyp
C excised using CO2 laser; (C) Laser ablation of the varices.
Chapter 16: Lasers in Phonomicrosurgery 177

A vocal fold cyst can be tackled very well with cold steel Cohen divided glottic webs into four grades of sever-
surgery using the mini-microflap technique and tangential ity depending on the length and thickness of the web.19
dissection. Laser offers the advantage of a very controlled Longer webs tend to be thicker than shorter ones and are
incision and layer-by-layer dissection, thereby reducing ­associated with a cartilaginous SG component. The clin-
the risk of cyst rupture and subsequent recurrence. ical presentation ranges from mild to severe dysphonia
SEVFC typically have anterior and posterior fibrotic with or without airway compromise.
bands (Figs. 4B and C), which anchor the cyst and have to
be divided by sharp dissection. This can be accomplished
Cohen’s Classification
effectively by laser, thus reducing the risk of cyst rupture.
The pathology may sometimes extend to the vocal lig- 1. Grade I: Thin anterior web; less than 35% of glottic
ament and creating a plane between the cyst wall and the length.
vocal ligament is quite difficult. Laser is very helpful in 2. Grade II: Thin to moderately thick anterior web;
these situations to release the adhesions between the cyst 35−50% of glottic length with potential cartilaginous
wall and the vocal ligament. SG component.
3. Grade III: Thick anterior web; 50−70% of glottic length
Glottic Web with cartilaginous SG component.
Anterior glottic webs can result from congenital or 4. Grade IV: Thick anterior web; 70−90% of glottic length
acquired causes. with cartilaginous SG component.


Figs. 4A to C: (A) Left subepithelial vocal fold cyst; (B) Anterior

fibrotic band being cut with the laser; (C) Posterior fibrotic band
C being cut with the laser.
178 Section 3: Phonosurgery

Treatment space and it typically affects both the vocal folds along
their entire length. There is a very strong etiological
In case of Grade I webs, there is no airway compromise
correlation with smoking. Other identified risk factors
and the voice impairment is usually slight. These patients
include laryngopharyngeal reflux and hypothyroidism.
usually do not require any intervention.
The patient presents with a low-pitched, gravelly voice.
Grade II webs result in significant dysphonia. Thin
Airway obstruction usually does not occur, unless pre­
webs can be divided in the midline with microscissors or
existing severe vocal fold edema is compounded by
laser. Slough at the anterior commissure has to be cleaned
vocal fold immobility or an upper/lower respiratory tract
after 1 week to 10 days to prevent rewebbing. These patients
are not advised any postoperative voice rest as that would
Patients are advised to stop smoking, else recurrence is
encourage rewebbing. In case of thick webs (Fig. 5A), the
endoscopic flap technique may be performed. Laser offers
the advantage of better hemostasis and precision cutting Subepithelial infiltration is not needed in these cases.
in the division of thick webs. An incision is made with the laser on the superior sur-
Endoscopic flap technique: The anterior glottic web is face of the vocal fold in the lateral aspect, beginning at
divided asymmetrically (along hypothetised medial edge the vocal process and stopping short at 3 mm from the
of one vocal fold), all the way up to the anterior commissure anterior commissure.1 The anterior commissure must be
(Fig. 5B). This results in the formation of a triangular mucosal kept untouched to prevent glottic stenosis. A flap elevator
flap. The undersurface of this flap and corres­ponding infra- is used to separate the polypoid tissue from the overlying
glottic vocal fold epithelium is made raw using laser in a epithelium and the underlying vocal ligament. The excess
defocused mode on low-power settings (Fig. 5C). The flap SLP can then be removed with a strong suction or a cup
is then draped over the infraglottic vocal fold and secured forceps.
in place with one or two 6-0 absorbable sutures (Figs. 5D One must avoid overzealous removal of the tissue from
to F). Mitomycin-C may be applied on the raw area over the Rienke’s space, especially in males, since it may result
the contralateral anterior commissure and anterior third in a very high-pitched voice postoperatively.
of vocal fold. As one vocal fold is covered with epithelium
postoperatively, chances of rewebbing are minimalized. Sulcus Vocalis
Grade III webs (Fig. 6A) are very thick with SG exten-
Patients with sulcus vocalis must be given maximum
sion and division with endoscopic placement of a keel is
speech therapy before proceeding to surgery. The patients
should have realistic expectations regarding the improve-
Endoscopic keel placement: The anterior glottic web is
divided in the midline up to the anterior commissure (Fig. ment in voice quality and should be prepared for multiple
6B) and the laser is then used to create a groove in the thyroid surgeries, if necessary.
cartilage, into which the keel is placed. A silastic keel can be A two-pronged strategy is employed in the surgical
fashioned from an oval piece of thin silastic which is folded treatment for sulcus vocalis, aimed at reducing the pho-
upon itself. A thin infant feeding tube can be stitched/glued natary gap and improving the pliability of lamina propria.
into place at the fold so that the anchoring suture material A large phonatary gap can be corrected by vocal fold aug-
can be fed into the infant feeding tube in order to prevent a mentation techniques or by medialization thyroplasty.
cut through. The keel can be sutured in place with the help The deficiency in the lamina propria can be addressed by
of a Lichtenberger needle or with the aid of 18-g angiocath- various techniques such as superficial vocal fold injection
eter for feeding the threads (Figs. 6C to H). with collagen-based material or fat, fat implantation, or
Grade IV webs result in severe airway compromise. sulcus excision with reapproximation. The laser is useful
These patients require a tracheostomy and an open sur- in sulcus excision.
gery for the glotto-subglottic stenosis.
Excision with Reapproximation
Reinke’s Edema (Polypoid Corditis) Subepithelial infiltration is done to clearly delineate the
This condition is characterized by accumulation of inflam­ area of the sulcus. An epithelial laser cordotomy is made
matory gelatinous amorphous material in the Reinke’s just lateral to the sulcus. Subepithelial dissection is carried
Chapter 16: Lasers in Phonomicrosurgery 179



Figs. 5A to F: (A) Grade II thick anterior glottic web; (B) The web is being divided asymmetrically along the right vocal fold perceived
edge using the CO2 laser in order to create an epithelial triangular flap; (C) Undersurface of the flap made raw using the laser; (D) Flap
being sutured to the infraglottic epithelium using 5-0 vicryl; (E) A knot is made outside the laryngoscope and then slid downwards using
a knot slider; (F) Knot in position.
180 Section 3: Phonosurgery



Figs. 6A to F: (A) Grade III thick anterior glottic web; (B) Web being released using the CO2 laser AcuBlade®; (C) 18-gram angiocatheter
passed from the anterior neck to the anterior subglottis; (D) 1-0 Prolene fed through this angiocatheter and then fed through infant feed-
ing tube of the silastic keel; (E) 1-0 Prolene suture loop being fed into another angiocatheter which has been passed from the anterior
neck to the anterior supraglottis. The previous subglottic 1-0 prolene with silastic keel is looped into this supraglottic prolene suture
which is pulled out so as to have a single 1-0 prolene holding the silastic keel; (F) Silastic keel being placed at the anterior commissure.
Chapter 16: Lasers in Phonomicrosurgery 181

Figs. 6G and H: (G) Silastic keel secured at the anterior commissure with sutures at both ends being anchored in subcutaneous tissues
of anterior neck; (H) Silastic keel in situ.

out and the invaginated epithelium is excised. The new Injection Cidofovir is a good option for tackling anterior
epithelial edges are then approximated using 5−0 or 6−0 commissure RRP.
absorbable sutures.
Recurrent Respiratory Papillomatosis
Vocal fold leukoplakia is essentially a white patch on the
Recurrent respiratory papillomatosis (RRP) is caused by surface of the vocal folds. Histopathologically, it can vary
human papilloma virus (HPV) characterized by benign from the very benign (hyperkeratosis of the epithelium)
epithelial growths in the respiratory tract (Fig. 7A), par- to frankly malignant (microinvasive squamous cell car-
ticularly at epithelial transition sites, resulting in dyspho- cinoma).1 The SEIT helps in determining the depth of
nia and airway compromise. As the name implies, the invasion. If the lesion involves the vocal ligament, the
condition is recurrent and most patients need multiple infiltrated fluid spreads all around the leukoplakic patch
surgeries in their lifetime. Hence, every attempt must be but does not lift the leukoplakic patch itself, thus creating
made to minimize the sequelae of surgery (vocal fold scar- a “doughnut effect”. If the leukoplakic patch involves only
ring, web formation, etc.) the epithelium, it gets lifted off by the infiltration. Surgical
Initial debulking of the papillomas can be achieved excision of a leukoplakic patch can be done with cold steel
using a microdebrider or CO2 laser in continuous mode. or laser. The author prefers to use cold steel for thin, small
Tiny fronds on the vocal folds are be removed by subepi­ leukoplakic patches and the CO2 laser for thick, keratotic
thelial infiltration (Fig. 7B) followed by microflap technique lesions (Figs. 8A to C). The excised tissue is sent for frozen
using the laser. No margin is required and the epithelial section examination after clearly marking the anterior,
cordotomy is placed immediately lateral to the papil- posterior, medial, and lateral margins. If the report sug-
loma (Figs. 7C to E). Laser offers the advantage of better gests malignancy, a 2 mm margin is taken all around the
hemostasis. One must remember that RRP is an epithe- lesion, including depth.19
lial disease and one must remain in as superficial a plane
as possible. HPV infects the basal cells of the epithelium. Chronic Granulomatous Diseases
So, the ideal plane of resection should be between the A number of chronic granulomatous lesions may involve
epithelial basement membrane and the SLP. When work- the larynx, either primarily or as a part of a generalized
ing at the anterior commissure, gross disease should be affection. These may be attributable to bacteria (e.g. tuber-
removed from one side only. The contralateral side should culosis, leprosy, syphilis, scleroma), to fungi (e.g. histoplas-
be addressed after 4−6 weeks in order to prevent webbing. mosis, blastomycosis, candidiasis), to an idiopathic cause
182 Section 3: Phonosurgery



Figs. 7A to E: (A) Recurrent respiratory papillomatosis involv-

ing the right vocal fold and anterior commissure; (B) Subepithe-
lial infiltration being performed; (C) Incision made just lateral to
the papilloma frond using CO2 laser; (D) Papilloma frond excised
using the microflap technique while preserving the infraglottic
E epithelium; (E) Postoperative appearance.

(e.g. Wegener’s granulomatosis, sarcoidosis), or to an auto- laryngitis remains one of the most common granulomatous
immune cause (amyloidosis). A discussion of the individual diseases of the larynx. A high index of suspicion is required
diseases is beyond the scope of this chapter. Tuberculous for diagnosis. There may be systemic pointers to the d­ isease
Chapter 16: Lasers in Phonomicrosurgery 183


Figs. 8A to C: (A) Bilateral vocal fold keratosis; (B) Excision

performed using CO2 laser after subepithelial infiltration technique;
C (C) Postoperative appearance.

such as the chest X-ray findings, sputum examination, Photoangiolytic Lasers

raised erythrocyte sedimentation rate (ESR). The diagnosis
of fungal laryngitis must be kept in mind immunocompro- The 585-nm PDL and the 532-nm KTP laser are photoan-
mised patients and those using steroid sprays. giolytic lasers, which selectively target oxyhemoglobin and
Granulomatous lesions of the larynx often mimic cause intravascular coagulation.
laryngeal malignancy and the role of a biopsy cannot be They can be delivered via a flexible laryngoscope
understated. A biopsy should be preferably taken from an in an office setting, thus providing a less invasive and
involved site, other than the true vocal folds. If it has to be more economic approach. These have been used to treat
taken from the true vocal folds, then it should be taken various benign laryngeal pathologies such as vascular
from the lateral aspect of the vocal fold. One must try and lesions, papillomatosis, anterior glottic web, granulomas.
avoid taking a biopsy from the medial vibratory edge of the Papillomas are very vascular lesions and the idea behind
vocal folds. using them in papillomatosis is to cause regression of the
The treatment of localized laryngeal amyloidosis is papillomas by selectively eradicating the tumor micro­
primarily by endoscopic excision. Accuracy, less bleeding, vasculature.
and less scarring leads to better preservation of vocal cord In a comparative analysis, Zeitels et al. reported the
function, which is easier to achieve with the use of laser pulsed KTP laser to be better as compared to PDL when
than conventional surgery.20 used for management of vocal fold ectasias and varices.21
184 Section 3: Phonosurgery

They reported the pulsed KTP laser to be substantially 5. Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on
­easier to use due to its enhanced hemostasis owing to its laryngeal and tracheal stenosis, benefits and complications.
Ann Otol Rhinol Lryngol. 2001;110(1):1-6.
longer pulse width. They also reported a significantly lesser
6. Zeitels SM, Burns JA. Laser applications in laryngology:
incidence of vessel wall rupture with KTP laser as com- past, present, and future. Otolaryngol Clin North Am.
pared to PDL. Zeitels et al. in their review also reported 2006;39(1):159-72.
pulsed KTP to be clinically more effective, structurally 7. Einstein A. Zur quantentheorie der Strahlung. Physikalische
more reliable, and less expensive as compared to PDL.22 Gesellschaft Zurich Miteilungen. 1916;18:47-62.
8. Maiman TH. Stimulated optical radiation in ruby. Nature.
PEARLS 1960;187:493-4.
■■ All clinicians using laser must undergo laser training, 9. Patel CKN. Continuous-wave laser action on vibrational-
including training in laser safety protocols. rotational transitions of CO2. Phys Rev. 1964;136:A1187-93.
■■ In case of benign glottis lesions, one must use the Acublade 1 0. Jako GJ. Laser surgery of the vocal cords. An experimental
scanner system as it ensures minimum thermal damage study with carbon dioxide lasers on dogs. Laryngoscope.
and optimal vocal outcome. Else, it is better to use cold 1972;82(12):2204-16.
steel. 1 1. Polanyi TG, Bredemeier HC, Davis TW. A CO2 laser for sur-
■■ Lasers have an inherent advantage in case of lesions which gical research. Med Biol Eng. 1970;8:541-8.
do not have a clearly defined margin such as amyloidosis. 1 2. Shapshay SM. Jako: “Laser surgery of the vocal cords;
an experimental study with carbon dioxide lasers on
■■ In case of vascular lesions with a feeding vessel, lasers are
dogs.” (Laryngoscope 1972;82:2204-2216). Laryngoscope.
useful in tackling the feeding vessels.
■■ Respect the layered microarchitecture of the vocal folds.
13. Anderson RR, Parrish JA. Selective photothermolysis: pre-
■■ The anterior commissure must be operated on only when
cise microsurgery by selective absorption of pulsed radia-
absolutely necessary.
tion. Science. 1983;220(4596):524-7.
■■ In case of benign pathologies of a recurrent nature, adopt
14. Patil UA, Dhami LD. Overview of lasers. Indian J Plast Surg.
a conservative approach during surgery to minimize the
sequelae of surgery.
15. Sataloff RT, Spiegel JR, Hawkshaw M, et al. Laser surgery
of the larynx: the case for caution. Ear Nose Throat J.
CONCLUSION 1992;71(11):593-5.
16. Remacle M, Lawson G, Nollevaux MC, et al. Current state
The use of laser in benign laryngeal lesions was once ques- of scanning micromanipulator applications with the carbon
tionable, in view of the potential adverse thermal effects. dioxide laser. Ann Otol Rhinol Laryngol. 2008;117(4):239-44.
1 7. Franco RA, Andrus JG. Common diagnoses and treatments
However, the AcuBlade® scanning micromanipulator tech­ in professional voice users. Otolaryngol Clin North Am.
nology with the superpulse/ultrapulse modes has added 2007;40(5):1025-61.
tremendous precision to phonomicrosurgical procedures 18. Hochman L, Sataloff RT, Hillman RE, et al. Ectasias and
with minimal thermal damage. varices of the vocal fold: clearing the striking zone. Ann
Otol Rhinol Laryngol. 1999;108(1):10-6.
19. Cohen SR. Congenital glottis webs in children: a retro-
REFERENCES spective review of 51 patients. Ann Otol Rhinol Laryngol.
1. Rosen CA, Simpson B. Principles of phonomicrosurgery. In: 20. Gallo A, de Vincentiis M, Manciocco V, et al. CO laser
Operative Techniques in Laryngology. Berlin, Heidelberg: cordectomy for early-stage glottis carcinoma: a long-term
Springer; 2008. pp. 63-76. follow-up of 156 cases. Laryngoscope. 2002;112(2):370-4.
2. Hirano M. Morphological structure of the vocal cord as 21. Behranwala KA, Ali Asgar B, Borges A, et al. Laser in treat-
a vibrator and its variations. Folia Phoniatr (Basel). 1974; ment of laryngeal amyloidosis. Indian J Otolaryngol Head
26(2):89-94. Neck Surg. 2004;56:46-8.
3. Sataloff RT, Spiegel JR, Heuer RJ, et al. Laryngeal mini-­ 22. Zeitels SM, Akst LM, Bums JA, et al. Pulsed angiolytic
microflap: a new technique and reassessment of the microflap laser treatment of ectasias and varices in singers. Ann Otol
saga. J voice. 1995;9(2):198-204. Rhinol Laryngol. 2006;115:571-80.
4. Zeitels SM, Hillman RE, Franco RA, et al. Voice and treat- 23. Zeitels SM, Burns JA. Office-based laryngeal laser surgery
ment outcome from phonosurgical management of early with the 532-nm pulsed-potassium-titanyl-phosphate laser.
glottis cancer. Ann Otol Rhinol Laryngol Suppl. 2002;190:3-20. Curr Opin Otolaryngol Head Neck Surg. 2007;15:394-400.
Lasers in Early Glottic Cancer

Vyas MN Prasad, Marc Remacle

INTRODUCTION engineering breakthroughs. We are now spoilt for choice

in the quality of fiber optics, operating microscopes, variety
Early glottic carcinoma treatment has seen a marked of lasers such as the CO2 laser which are capable of
shift in its management in the Western world over the being delivered through a microscope or by flexible fiber
last three decades. Whereas before, where treatment was delivered laser systems using the CO2, potassium titanyl
either radiotherapy or open surgery (partial laryngectomy phosphate (KTP), pulse dye, and thulium laser to name
or even total laryngectomy), it is now common to treat a few. Finally, the ability to incorporate laser fibers with
these tumors via transoral laser microsurgery. Laser sur­ rigid and semiflexible robotic-assisted units [transoral
gery has gained sufficient acceptance as an oncologically robotic surgery (TORS)] that negotiate the complex non­
safe, less morbid, and functionally equivalent modality linear anatomy of the upper aerodigestive tract will allow
to conventional radiotherapy. It is also cost effective and for further progression of the treatment of laryngeal cancer
repeatable with the option of open surgery and radiothe­ in the coming decades. In this chapter, it is our intention
rapy in the event of recurrence or a new primary. Local to provide the reader with the basis for incorporating laser
control rates and laryngeal preservation rates are equal surgery in the management of early glottic cancer and
to open surgery and better than radiotherapy. We provide share our experience and those of others over the last three
the historical backdrop of the initial use of the CO2 laser decades since undertaking this relatively safe, efficient,
in the treatment of early laryngeal cancer coupled to the and effective modality.
operating microscope with the evolution of computer-
assisted technology to help improve laser excision accuracy
and reduce thermal damage to surrounding unaffected HISTORICAL ASPECTS
tissue in order to be oncologically effective yet preserving Although endolaryngeal surgery for early glottic cancer
function of the swallow mechanism, voice, and airway. was described a century or so ago prior to the introduction
A synopsis of the types and subtypes of cordectomies is of lasers, it was generally performed in a far less sophisti­
discussed and finally the emerging roles of newer tech­ cated manner in keeping with the technology of the time
nologies such as robotics in the upper aerodigestive tract and was therefore rejected by surgeons of that era. The
are explored. introduction of the operating microscope with suspension
The diagnosis and treatment of early glottic cancer laryngoscopy by Kleinsasser allowed for the resection of
(TNM classification: Tis, T1, and T2) has seen a paradigm glottic lesions using cold steel and monopolar cautery.1
shift over the last 40 years. Previously, transoral surgery Resection of laryngeal lesions evolved from simple punch
was viewed as being inadequate for exposure, poor for forceps to surgical diathermy.2,3 Kumar Patel’s invention of
visualization, constrained for instrumentation, hazardous the CO2 laser in the early 1960s4 was to provide the pre­
for bleeding into the airway, and compromising for onco­ cision that Jako and Strong would utilize in their seminal
logical success. It is now quite the opposite. Great strides work in the early 1970s.5-7 Over the subsequent decades,
have been made in the realm of minimally invasive surgery laser technology evolved with medicine and a number of
using a variety of technical advancements and medical lasers with different absorptive properties that could be
186 Section 3: Phonosurgery

used for a variety of lesions in the larynx were developed. Early Glottic Cancer
Laser resection became accepted as an alternative to open
surgery and radiotherapy. The advantages of precise abla­ The definition of “early” cancers of the larynx can be mis­
tion, excision under magnification with concurrent hemo­ construed depending on whether clinicians, pathologists,
stasis made the laser an ideal tool for operating on selected or cell biologists are questioned.22 For the purpose of this
cases of glottic cancer. Functional results were found to be chapter, we are not describing the morphological pattern
as good if not better than open surgery and oncological of vocal fold carcinoma but the clinical stages [(stages I
results were equivalent to the alternatives. Surgeons from and II according to Union for International Cancer Control
both sides of the Atlantic produced similar results.8-14 This (UICC) and American Joint Committee on Cancer (AJCC)]
cemented the role of lasers in early glottic cancers and of the disease, namely Tis, T1, and T2. The vast proportion
paved the way for its use in more advanced disease.15 En of glottic cancers is squamous cell carcinomas (SCC) with
bloc oncological resection which was the mantra origi­ a much smaller proportion of other histological subtypes.
nally was challenged and a radically different approach to Verrucous carcinomas predominantly involve the glottis
resection of bigger laryngeal and hypopharyngeal cancers and are considered an atypical variant of SCC. They do not
by going through cancerous tissue was to become more behave aggressively, rarely infiltrate, and do not metasta­
accepted and oncologically safe.11 Finally, over time, lasers size.22 These cancers are suitable for transoral laser exci­
have become readily portable, used in the office and are sion given their biological behavior.
relatively cost effective.
All patients presenting with laryngeal dysplasia and car­
Leukoplakia cinoma are assessed initially in the office-setting where a
thorough history and examination of the head and neck are
Vocal fold leukoplakia is considered a premalignant
performed. Thereafter, the “gold standard” examination
condition (Gr. white plaque) and is seen frequently in
using flexible or rigid fiber optic endoscopy and videola­
clinical practice. It is indicative of keratin production on ryngostroboscopy (VLS) with still and video image acqui­
the glottic epithelium and is often due to chronic inflam­ sition, recording, and storage in the patient’s database is
mation. Histologically, leukoplakia can span the diverse advocated. Here, magnified images with increasing clarity
range from hyperkeratosis to carcinoma in situ (Figs. 1A from better quality illumination and endoscopes (e.g. dis­
to D). Keratosis is however a histological term denoting tal chip on tip scopes) provide excellent appreciation of
increased keratin on the squamous epithelium.16,17 Risk the lesions concerned. Special attention should be taken
factors include smoking and alcohol, gastroesophageal when examining glottic lesions at the anterior commis­
reflux disease, and human papilloma virus infection. sure, in the ventricle and the inferior surface of the vocal
Confidently diagnosing leukoplakia is difficult even at the fold. Subtle reduction in the mobility of the vocal fold will
histopathological level. Inter- and intrarater variability is upstage the tumor either because of the tumor mass and/
known to be high and impacts on subsequent manage­ or the involvement of the vocal muscles. VLS allows for
ment options. Moreover, classification systems abound careful assessment of the mucosal wave and provides the
for laryngeal premalignant conditions, e.g. the 2005 clinician with information about the likely depth of pene­
World Health Organisation,18 Ljubljana Classification,19 tration of the lesion. Preservation of the mucosal wave
and Squamous Intraepithelial Neoplasia20 systems— in our experience almost always reflects on the lack of
being the most widely used. The use of the CO2 laser in involvement of the vocal ligament and corresponds to car­
the management of leukoplakia has been well described cinoma in situ at most. Reduced or absent mucosal waves
in the literature.21 It has been used for both diagnostic are suspicious of tumors invading the basal membrane
purposes in the form of biopsies [ELS (European Laryn­ into the lamina propria. Where the diagnosis of an invasive
gological Society) type I cordectomy] and therapy. It has tumor and/or involvement of the anterior commissure is
also been used in an ablative mode for therapeutic use in strongly suspected, imaging prior to biopsy is valuable to
dysplasias and smaller Tis. stage the tumor without postbiopsy artifact.
Chapter 17: Lasers in Early Glottic Cancer 187


Figs. 1A to D: (A) Hyperplasia; (B) Dysplasia; (C) Microinvasive carcinoma; (D) Hyperplasia/dysplasia or carcinoma in situ.

Imaging In Theater
Cross-sectional imaging of the larynx is essential for accu­ Endoscopic assessment and biopsy of early glottic tumors
rate staging, and reliance on endoscopic information is conducted almost always under general anesthesia while
alone can result in under diagnosis in approximately 50% in the operating theater. Where necessary, the anesthetist
of cases.23 Computed tomography (CT) is considered the should be made aware of potential difficulties prior to the
imaging modality of choice. It is quick and is hardly affected procedure especially from an anatomical point of view as
by breathing artifact and patient compliance. Magnetic these cases can be equally challenging to both specialists.
resonance imaging (MRI) does have its own advantages in Patients are consented appropriately prior to the proce­
assessing thyroid cartilage involvement especially at the dure and both anesthetic and surgical risks are assessed
anterior commissure and the spread into the paraglot­ accordingly. Patients with loose teeth, poor mouth open­
tic space. Multidetector high-resolution CT (MDCT) with ing, and with a high Mallampati score can be challenging.
three-dimensional (3-D) volume-rendered virtual laryn­ The risks and benefits of the procedure should be carefully
goscopy images and high-field MRI show promise in better explained to the patient with full informed consent given.
provision of tumor extent. The timing of imaging therefore is Thereafter, it is important to assess the upper aerodigestive
important in not upstaging tumors that have been recently tract for any other mucosal lesions (panendoscopy).
biopsied but should be balanced with the ability to avoid Rigid laryngoscopy with multiangled fiber optics using
undue delay in obtaining tissue diagnosis. a variety of rigid endoscopes (0°, 30°, 70°, and 120°) and
188 Section 3: Phonosurgery

image acquisition stack systems unlike in-office systems laryngeal cancer. These include the CO2 laser, KTP, diode,
provide the ability to see areas that are obscured during pulse dye, Nd:YAG, Holmium and Thulium lasers as well
in-office examination. Thereafter, two-handed instrumen­ as photodynamic therapy (PDT) in small and superficial
tation with the operating microscope allows for instru­ lesions.25 The CO2 laser is however the laser of choice for
mentation of the larynx giving the surgeon a “feel” for the the vast majority of surgeons. It is connected to an operat­
glottic structures. Microspatulas and probes help to evert ing microscope and the aiming beam is focused onto the
the true and false cords and assess their inferior surfaces area of concern without any carrying handles in the way.
and the ventricle while probes can help assess for aryte­ It provides hemostasis while vaporizing tissue and the
noid restriction of movement. The use of different laryn­ thermal damage zone is limited, shallow, and with current
goscopes can also provide further information including technology such as the AcuSpot® and AcuBlade® scanning
epiglottic, anterior commissure, and preepiglottic space system (Figs. 2A to E), allows for precise extirpation with
spread. Removal of the endotracheal tube allows for rigid limited charring to the underlying tissue facilitating more
tracheoscopy prior to biopsy. accurate assessment of margins (AcuBlade®, Lumenis,
Although VLS does provide fairly accurate evaluation
Santa Clara, CA, USA).26,27
of the mucosal wave and hence information regarding
sparing of the vocal ligament by the early glottic cancer,
some surgeons also prefer injection of normal saline into CO2 Laser—AcuBlade® Scanner System
Reinke’s space (superficial lamina propria) to allow for The AcuBlade® scanner system is a computerized mecha­
hydrodissection of the lesion off the vocal ligament. In very nism consisting of rotating mirrors that are attached to
small lesions which may have only progressed to microin­ the micromanipulator. The resulting beam that is prepro­
vasive carcinoma (0.5–2 mm maximum depth of invasion grammed and emitted from the scanning device to the
beyond basement membrane), information from saline larynx can be “shaped” in a straight line or curved of
infusion should be combined with that of VLS and where varying lengths (0.7–4 mm) with varying depths of pene­
there is a lack of concordance, the worse result is applied tration through the laryngeal tissue (0.2–2 mm). The
for the subsequent cordectomy.24 curvature is akin to that of the curved microscissors
The other benefit and purpose of a thorough panendo­ designed by Bouchayer. The latest addition to the family of
scopy and laryngeal biopsy is to ascertain if the patient is a CO2 lasers in the Lumenis Acupulse Duo® which combines
suitable candidate for transoral laser surgery as opposed to fiber and free beam technology in one laser unit. Software
radiotherapy after staging is complete and the patient has integrated into the system called “Surgitouch™” allows for
been given the tumor board’s recommendations. It is vital customized beam delivery using the AcuBlade® system
to understand that the limitations of endolaryngeal micro­ and selective ablation to 150 µm results in minimal
surgery for cancers of the larynx are very much dependent thermal damage to adjacent tissue (Fig. 3).
on the ease of access to the larynx. Surgeons who struggle Choice of the depth of penetration (number of passes)
to get a biopsy of the lesion and/or appraise the larynx are is software calculated and based on the average absorption
more than likely to leave tumor behind and/or have com­ of the CO2 laser by soft tissues in situ. Thus, while in scan­
plications which were unwarranted. Locoregional spread ning mode, the computer within the laser will automati­
in early glottic cancers is very rare. Nevertheless, staging cally select how much power and pulse length is required to
scans of the neck and chest are performed routinely. In deliver the laser energy in single pulse mode. Repeated and
centers where access to high-quality ultrasound scans is continuous delivery of laser in continuous or superpulsed
readily available, fine needle aspiration cytology of any energy mode allows for the surgeon to choose how the laser
suspicious nodes surpasses the diagnostic accuracy of CT energy is generated and thereafter delivered, allowing for
and MRI with accuracy in lymph nodes less than 5 mm control of the extent of thermal damage and the thermal
in diameter. Positron emission tomography-computed relaxation effect to minimize collateral damage, improve
tomography (PET-CT) is also becoming more popular in healing, and preserve function. This is quite often the case
some centers where availability and cost are unrestrictive. with patients feeding normally very shortly after surgery
and not requiring prolonged nasogastric tube-assisted diet.
TYPES OF LASERS Given the versatility of the scanning technology cou­
There are a variety of lasers that have been developed pled with superpulse energy delivery, the laser can cut
which have been shown to be effective in the treatment of fine lines (straight or curved) with a precision of 250 µm
Chapter 17: Lasers in Early Glottic Cancer 189



Figs. 2A to E: CO2 laser technology: (A) Micromanipulator—

AcuSpot®; (B) AcuBlade® scanner; (C) Scanning mode linear cut;
(D) Scanning mode—ablation circle; and (E) AcuBlade® operating
E modes.

and also ablate tissue rapidly as a circle/spot at minimal obviating the need for a covering tracheostomy. Further­
depths of penetration, i.e. 100 µm at the very minimum— more, given the minimal tissue necrosis, ablation of the
hence allowing for quick resurfacing of the epithelium, etc. laryngeal cartilages induces very little perichondritis. Given
The after-effects are minimal with little charring or edema the dual modality of tissue interaction, i.e. v­ aporization of
190 Section 3: Phonosurgery

Subepithelial Cordectomy (Type I)

This procedure is diagnostic and in cases of hyperplasia,
dysplasia, or carcinoma in situ where the lesions are by
definition limited to the epithelium, then the procedure
can be therapeutic (Figs. 5A to C). The pathologist is pre­
sented with a strip of epithelium and superficial lamina
propria. The vocal ligament is spared. In rare instances,
not all the epithelium needs to be resected where the
epithelial changes are restricted to only a small area of
the vocal fold.

Subligamental Cordectomy (Type II)

This procedure involves the resection of the epithelium,
Reinke’s space, and the vocal ligament. The laser incision
is performed between the vocalis muscle, sparing it and
Fig. 3: Lumenis Acupulse Duo® CO2 laser.
the vocal ligament. This procedure may span from the tip
of the vocal process to the anterior commissure. It is indi­
water by the infrared wavelength creating steam and the cated when VLS shows loss of the mucosal wave or saline
denaturation of proteins forming a coagulum, there may infusion is incapable of hydrodissecting the lesion off the
vocal ligament. This procedure is ideal for microinvasive
be further tissue effects. These include the sealing of small
carcinomas and severe carcinoma in situ (Figs. 6A and B).
blood vessels and lymphatics perhaps helping to reduce
metastases from surgery.
Transmuscular Cordectomy (Type III)
ADVANTAGES OF LASER SURGERY The vocalis muscle is incised using the laser but extension
is limited laterally to spare the thyroarytenoid muscle. Like
Laser surgery is by and large quicker and repeatable in the type II, the extent of the procedure spans the entire
the event that there is any concern for residual or recur­ length of the vocal fold. The ventricular folds are occa­
rent disease. It is cheaper than radiotherapy and has a sionally excised to allow for better visualization of the true
relatively short hospital stay, quick restoration of swallow vocal fold. This procedure is indicated for small cancers
function, and acceptable speech to most patients without infiltrating the vocalis muscle and not affecting the mobil­
the medium- and long-term morbidity seen in radiothe­ ity of the vocal fold.
rapy.28-32 The oncological results are comparable to radio­
therapy and despite poorer speech in the first year after Total or Complete Cordectomy (Type IV)
treatment, patients can elect to have surgery for voice
restoration.33 This procedure is indicated for T1a cancers of the glottis.
It is therapeutic by definition