visual documentation and imaging of laryx.pptx

*VISUAL DOCUMENTATION
AND IMAGING OF LARYNX

*INRODUCTION
CT and MRI have become the procedures of choice for
defining mass lesions and traumatic abnormalities and
supplement the findings at laryngoscopy when additional
diagnostic information is required to plan treatment.
Diagnosis and extent of involvement of inflammatory
lesions such as croup, epiglottitis, and retropharyngeal
abscess can be confirmed with imaging.
Cross-sectional imaging is extremely useful in evaluating
the patient with vocal cord paralysis and laryngeal
carcinoma.

*INTRODUCTION
Laryngeal endoscopy, using flexible or rigid endoscopes, is used
to examine vocal fold structure and gross function.
 Videostroboscopy is used to examine vocal fold vibration
patterns and the relationship between the body and the cover.
High-speed digital imaging complements endoscopy and
stroboscopy, showing details of short and aperiodic vibration as
well as quantifying vibration parameters.
Narrow-band imaging is a newer visualization technique that
uses the tissue's light absorption characteristics to show vascular
detail.

*Normal airway
Technique:
Plain films remain an effective and inexpensive screening
examination for acute airway obstruction.
 Except in rare circumstances, plain-filmexamination of
the airway should include anteroposterior and lateral
radiography of the pharynx and laryngotracheal air column.
In cooperative patients, these films should be exposed
during inspiration with the patient upright because acute
respiratory obstruction may be exacerbated in the
recumbent position.

When plain films are inconclusive, fluoroscopy and barium
studies of the esophagus may be required for diagnosis.
Anatomy:
Lateral radiography is excellent for identifying the tongue,
adenoids, tonsils, epiglottis, aryepiglottic folds, pyriform
sinuses, laryngeal ventricle, and subglottic trachea.
A healthy upper airway in a 20-month-old child. The following structures are well visualized: (1) palatine
tonsils .(2) epiglottis, (3) body of the hyoid bone ,(4) aryepiglottic folds ,(5)laryngeal ventricl (6)subglottic
airway, vallecula (V), and pyriform sinus (P).)

Lateral airway radiography should be obtained as much as
possible in full inspiration with the neck extended. If the
study is performed during expiration or with forward flexion
of the neck, the retropharyngeal soft tissue in children
bulges anteriorly and may simulate a retropharyngeal
Pseudoretropharyngeal mass. A, A retropharyngeal mass (M) is suggested in this child, who was
examined with the neck flexed and the airway only partially distended. B, Healthy
retropharyngeal soft tissue is seen when the examination is repeated during inspiration with the
neck extended.

* Clinical aspects of larygeal imaging:
Inflammatory Disease of the Larynx:
Epiglottitis:
*Epiglottitis is an inflammation of the epiglottis caused by the
bacteria Haemophilus influenzae.
* The entire supraglottic airway may be involved, but the
epiglottis and aryepiglottic folds are most extensively involved.
*These normally well-defined thin structures become
edematous, enlarged, and unsharp, resulting in a rounded,
thumblike density in place of the epiglottis.
*The edema often encroaches on the vallecula and rarely may
extend to the posterior pharyngeal wall. In addition, the
hypopharynx and pyriform sinuses are usually mildly to
moderately overdistended.

The changes of epiglottitis are shown best on lateral
radiography
Epiglottitis. Marked thickening of the
epiglottis (arrow) and aryepiglottic
folds (arrowheads) is seen. Mild
hypopharyngeal overdistention is
also present
 On occasion, an omega
epiglottis—a normal anatomic
variant in children in which
the epiglottis is floppy,
vertically positioned, and
resembles thecapital Greek
letter “omega”—may be
misdiagnosed as epiglottitis.

CROUP:
Croup is an inflammation of the subglottic larynx usually caused by
parainfluenza virus type 1. It typically occurs in young children.
Radiographic studies are not indicated or obtained routinely in patients
with croup but are useful in confusing cases, primarily to exclude other
causes of stridor. The radiographic changes are the result of inflammatory
edema affecting the larynx and subglottic tissue
In contrast to congenital subglottic stenosis, narrowing of the subglottic
portion of the trachea is not fixed and may improve on expiration.The
lateral view of the neck shows the narrowing may be noted. This
projection shows hypopharyngeal airway distention, but more importantly
it establishes that theepiglottis and aryepiglottic folds are normal.

Membranous or bacterial croup and viral croup may present with similar
symptoms; however, membranous croup is characterized by diffuse
inflammation of the larynx, trachea, and bronchi with adherent exudate
and mucus on the surface of the upper tracheal mucosa

Radiographically, the frontal view is
most helpful in the diagnosis.
Symmetric subglottic airway narrowing
or “penciling” of the airway is the
major radiographic finding.
Radiography shows subglottic
narrowing and multiple tracheal
soft tissue excrescences.These
intraluminal lesions can be
mistaken for foreign bodies, so
clinical correlation is required for
diagnosis.
Membranous croup. Multiple
irregular membranes (arrows)
are present in the subglottic
airway

Retropharyngeal Abscess:
Retropharyngeal abscess results from suppuration of
retropharyngeal lymph nodes in patients with upper
respiratory tract infection or from perforation of the
pharynx or upper esophagus by a foreign body. If the
abscess compresses the larynx and upper trachea,
symptoms of upper airway obstruction develop.
Lateral soft tissue radiography of the neck will show fixed
thickening of the retropharyngeal soft tissues, anterior
displacement of the airway, reversal of normal cervical
lordosis, and occasionally gas bubbles within the abscess.

 Retropharyngeal abscess secondary to
foreign body perforation of the
esophagus. The prevertebral soft
tissues are markedly swollen, and the
trachea is displaced anteriorly (small
arrows). Large arrow points to a
metallic foreign body.
 The retropharyngeal space should
not exceed 7mm as measured from
the most anterior aspect of C2 to
the posterior pharyngeal wall. At
C6, the thickness of the
retropharyngeal tissues should not
be greater than 14 mm in children
and 22mm in adults.

CT and MRI superbly evaluate the retropharyngeal space.
Abscess will appear hypodense on CT, hypointense on T1-
weighted, and hyperintense on T2-weighted magnetic
resonance (MR) images,reflecting the presence of
liquefaction.Ring enhancement may be seen following
administration of intravenous contrast.

Retropharyngeal abscess.
Enhanced CT image of the
neck demonstrates a fluid
collection in the left
retropharyngeal space

Differentiation between retropharyngeal abscess and
adenitis is difficult on CT because both processes cause
hypodense regions within the inflammatory mass.
If air bubbles or a foreign body is present within the mass,
the diagnosis of a retropharyngeal abscess is more likely
Thickening of the retropharyngeal soft tissues also can
occur secondary to bleeding and edema from cervical spine
trauma, lymphadenopathy(e.g.,lymphoma,tuberculosis),or
retropharyngeal tumors (e.g., cystic
hygroma,neuroblastoma,hemangioma, retropharyngeal
goiter,cancer).The imaging findings should therefore be
correlated with the clinical history.

*Laryngomalacia:
*Laryngomalacia or congenital flaccid larynx is one of the
most common causes of inspiratory stridor in the neonate
and infant.Laryngoscopy shows flaccidity of the
epiglottis,aryepiglottic folds, or the entire larynx, which
collapses during inspiration.
*The primary reasons for laryngoscopy and radiography are
to exclude other causes of congenital stridor (e.g., cysts,
webs, tumors, stenoses). In most children, the symptoms
disappear by 1 year of age.

Vocal Cord Paralysis:
Paralysis of the vocal cord may be caused by any process involving the
vagus nerve or its recurrent laryngeal branch between the jugular
foramen and its entrance into the larynx.
Almost 75% of patients have unilateral paralysis.Almost 90% of
paralyses are caused by lesions that compress the nerve along
peripherally located segments, and only 10% originate in the central
nervous system or before the nerve exits the jugular foramen
Specific peripheral causes include neoplasm (36%); postoperative
complications, such as from parathyroid and thyroid surgery (25%); and
inflammation (13%). Some cases are idiopathic.Congenital central
nervous system anomalies are often associated with childhood vocal
cord paralysis.

Imaging signs of cord paralysis include paramedian position of the
cords, displaced arytenoid cartilage, ipsilateral dilation of the
pyriform sinus, tilting of the thyroid cartilage, and prominent
laryngeal ventricle.
Although plain-film radiography, fluoroscopy, and CT can evaluate
vocal cord mobility, abnormal vocal cord motion is generally
diagnosed by laryngoscopy.
Left true vocal cord paralysis. A,
During phonation, both vocal
cords are in a paramedian
location (arrows). B, During
inspiration, the left true vocal
cord remains in a paramedian
position (arrow), whereas
there is abduction of the normal
right true vocal cord.

Benign Laryngeal Masses
Benign neoplasms can cause respiratory obstruction.
Symptoms and imaging features depend on tumor distribution
and extent. CT is the preferred screening method because of
its widespread availability and superior information.

Subglottic hemangioma is the most common laryngeal and
upper tracheal neoplasm in the newborn and infant. The lesion
typically appears as a well-defined mass in the posterior or
lateral portion of the subglottic airway
Subglottic hemangioma. Lateral view shows a
soft tissue mass (arrows) in the posterior
portion of the subglottic airway.
 The subglottic narrowing is
usually eccentric; however,
circumferential narrowing
suggestive of croup may also be
seen. Additional hemangiomas
may occur on the skin or
elsewhere in the body.

Squamous papillomas,the most frequent laryngeal tumors in
children, have also been reported in adults.
The imaging shows single or multiple intraluminal soft tissue
nodules are seen in the glottis or in the tracheal air column.Because
papillomas may extend to the bronchial tree or pulmonary
parenchyma, chest CT is extremely important in defining the extent
of disease.
Laryngotracheal papillomatosis. Oblique view
from a bronchogram shows multiple nodules
(arrows) of varying sizes in the glottic and
subglottic airway.
 Papillomas also may appear as
well-defined discrete pulmonary
nodules that eventually cavitate,
forming multiple thin-walled
cystic lesions.

Laryngocele:
A laryngocele is an abnormal elongation and expansion of the
saccule of the laryngeal ventricle
Although laryngoceles are usually asymptomatic, large lesions
may be associated with airway obstruction and vocal cord
paralysis.
Laryngoceles within the paraglottic space and confined by
the thyroid lamina are termed internal.
Lesions that pierce the thyrohyoid membrane to present in
the lateral neck are termed external. Most cases are a
combination of external and internal lesions and are referred
to as mixed.
Laryngoceles are usually visualized as sharply defined air-
containing structures on imaging

Mixed laryngocele. Frontal view
shows the large internal (I) and
external (E) components of the
laryngocele with compression of
the supraglottic airway (arrows)
Internal laryngocele. Computed tomography shows
the air-filled laryngocele (L) filling the right
paraglottic space and compressing the laryngeal
vestibule (V). The hyoid bone (H) is also seen.

*CT AND MRI:
CT is a proven imaging technique for evaluating patients with laryngeal
carcinoma. In most patients, CT shows more extensive disease than is
initially appreciated by laryngoscopy.

CT and MRI are excellent noninvasive methods capable of three-
dimensional (3D) anatomic display of portions of the larynx that are not
well examined by laryngoscopy
The cross-sectional imaging provided by CT allows evaluation of the
intrinsic and deep soft tissues of the larynx and the cartilaginous
skeleton.
MRI provides anatomic information on the neck that compares favorably
with CT.

Advantages of MRI over CT:
MRI has excellent soft tissue contrast, which is superior to
CT.Multiplanar display enables coronal, transverse, and
sagittal anatomic formatting, whereas CT is usually limited to
the transverse plane.
MRI uses no ionizing radiation and is not plagued by artifacts
caused by beam hardening,dental amalgam,or poor beam
penetration of the shoulders.
Disadvantages of MRI over CT:
It is slower than CT, and therefore motion artifacts from
breathing, carotid artery pulsations, and swallowing may
degrade
MRI does not image cortical bone or calcifications well.
MRI is contraindicated in patients with cardiac pacemakers,
metallic cochlear implants, and cerebral aneurysm clips.

Technique:
Spiral (helical) CT using multidetector technology and volumetric data
sets has largely replaced conventional dynamic CT (slice-by-slice
acquisition) in most medical centers.
Spiral CT permits rapid scanning of large volumes of tissues during quiet
respiration.Spiral images are less susceptible to patient motion than
conventional CT.
Volumetric spiral data permit multiplanar and 3D reconstruction.The
amount of intravenous contrast may be reduced compared with
dynamic CT.
Iodinated contrast is administered intravenously to distinguish
nonenhancing lymph nodes from enhancing vessels.

3D CT is currently being used for radiotherapy planning.
In MRI Sagittal, transverse, and coronal T1-weighted images best
display anatomic relationships. T1-weighted and T2-weighted
transverse images further define the signal characteristics of the
tissues. Sections are usually 3 to 5 mm thick.
Combined positron emission tomography (PET) CT is a new
technique in which near simultaneously acquired PET and CT
information is superimposed. This image fusion has the advantage of
comparing superior sensitive functional PET data with the superior
anatomic data offered by CT.
PET CT is very useful in post-therapy patients for evidence of
recurrent tumor, analysis of ambiguous lymph nodes and soft tissue
masses, and verification of biopsy sites

Combined positron emission tomography/computed tomography (PET/CT) image of the neck
demonstrating increased PET activity (arrowhead) superimposed on the corresponding CT image.
The increased PET activity indicates hypermetabolic tumor. The CT image allows accurate
anatomic localization of this tumor.

Normal anatomy on computed tomography showing
supraglottic larynx .The two air-filled valleculae (V) separated
by the median glossoepiglottic fold are seen anterior to the
epiglottis (arrows). The jugular vein (j), internal carotid artery
(i), external carotid artery (e), sternocleidomastoid muscle (S),
and hyoid bone (H) are also seen.

Normal anatomy of the supraglottic larynx on magnetic resonance
imaging. A, A fat-filled pre-epiglottic space (PES) is anterior to the
epiglottis (arrows). The internal carotid artery (c) and internal
jugular
vein (j) are also seen. Fat on this sequence is higher in signal
intensity than the epiglottis or muscle. B,Five milimeters inferiorly
the pyriform sinuses (P) are lateral to the aryepiglottic folds
(arrowheads).

Normal anatomy of the false and true
vocal cords on computed tomography.
A, The false vocal cords (arrows), lie at
the level of the foot processes (f) of the
arytenoid cartilages. The superior thyroid
notch (arrowhead) is noted anteriorly
between the thyroid laminae. The thyroid
cartilage is incompletely calcified, which
is a normal variation that should not be
mistaken for cartilage destruction. The
jugular vein (J) and carotid artery (C) are
also seen.
B, Four millimeters inferiorly, the true
vocal cords (white arrow) are seen at the
level of the vocal processes (arrowhead)
of the arytenoid cartilages (A), located
superolateral to the upper posterior
border of the cricoid cartilage (Cr).
Thyroid lamina join anteriorly to form
the laryngeal prominence. Anterior
commissure is aso seen(black arrow)

Normal anatomy of the true vocal cords on magnetic resonance imaging.
The true cords (arrowheads) are of soft tissue intensity. The arytenoids
(small arrows) and thyroid lamina (curved arrow) are seen
as high signal intensity on this sequence because of fatty marrow. The
superior portion of the cricoid is also shown (arrow).

Normal anatomy of the
midsagittal plane on magnetic
resonance imaging. Epiglottis
(white arrow), fat-containing
pre-epiglottic space (black
arrow), extrinsic strap muscles
(black arrowhead), arytenoid
cartilages and muscles (small
black arrowhead), hyoid bone
(curved black arrow), and
cricoid cartilage (curved white
arrow) are shown. The soft
palate (S), tongue (T), and
spinal cord (C) are also seen.

Normal anatomy of the coronal plane on
magnetic resonance imaging. Cricoid
cartilage (large black arrowhead), thyroid
cartilage (small black arrowhead), true
cords (white arrowhead), and
aryepiglottic folds (white arrow) are
shown.

*Laryngeal videoendoscopy
Laryngeal videoendoscopy is a clinical
tool that is used to examine vocal fold
structure and gross function.
It is used to diagnose and document
voice and laryngeal disorders and plan
treatment.
Laryngeal
Videoendoscopy
Rigid
Flexibl
e

*Rigid endoscopy:
Advantages:
*Rigid scopes have the advantage of high resolution
with bright, clear pictures. Contrast is excellent,
there is a large selection of viewing angles
*image is more accurately magnified than with a
flexible endoscope.
*The examination is simple and does not usually require
topical anesthesia.
*Rigid endoscopes used with LVES are usually 70- or 90-
degree scopes.

Disadvantges:

The primary limitation of the rigid endoscope is that
phonation is limited to sustained vowels, most commonly
“ee.”

Because visualization with a 70-degree rigid endoscope
usually requires an extended neck and protruded tongue,
the size of a glottic gap might appear exaggerated with the
rigid endoscope.To counteract this problem, Rammage and
colleagues suggest a lateral approach to the larynx to
decrease neck extension during the examination.
Alternatively, a 90-degree endoscope does not require the
same amount of neck extension as the 70-degree endoscope
does.

mobility of the arytenoids might not be accurately
assessed via rigid endoscopy; often, it appears as if
there is a vocal fold paresis when the perceived lack of
motion is, in actuality, an artifact of the tongue
protrusion and neck extension.
disorders more evident in connected speech than in
sustained vowels (e.g., muscle tension dysphonia and
spasmodic dysphonia) are not as well documented with
rigid endoscopy as they are with flexible endoscopy.

Technique of Rigid laryngeal videoendoscopy:

The laryngeal examination with a 70-degree rigid endoscope
is conducted with the patient bending slightly forward from
the hips while maintaining a straight back.

The neck and chin are extended, and the tongue is
protruded and wrapped in gauze and holded gently during
the examination. The endoscope is advanced just under the
uvula or between the uvula and faucial pillars until the
epiglottis is visualized.
.

The examiner might need to flex the wrist to tilt the
endoscope tip inferiorly. The angle can be varied for

The patient is then instructed to sustain “ee,” which
moves the epiglottis anteriorly for a better view of the
vocal folds
Examination with the 90-degree endoscope is similar, but
the patient does not need to bend forward or extend the
neck.
 Another difference is the angle; the tip of the 90-degree
scope is positioned with minimal tilt so that the light is
parallel to the surface of the vocal folds. This type of
endoscope is often preferable for viewing the larynx when a
wider viewing angle is desired.
A longer lens or a zoom lens might be necessary for
adequate visualization of vocal fold details.

Defogging can be done with liquid defogger, hot (not
boiling) water,soap film, surgical wax, and holding the
endoscope lens briefly against the patient's cheek or the
side of the tongue.
The examination is generally tolerated without topical
anesthesia, but a small amount of benzocaine topical spray
or a similar product is sometimes useful and does not
appear to affect examination results

*Flexible endoscopy:
Advantages:
The primary advantage of the flexible endoscope is
the ability to view the larynx dynamically—that is,
during natural functions such as speech and singing.
 Arytenoid mobility and the glottic gap can be more
accurately described with flexible than with rigid
endoscopy because of the neutral tongue and neck
positions.
Flexible endoscopy also allows the clinician to assess
the nasal cavity and velopharyngeal port during the
same examination.

 Flexible endoscopy is preferred when the
question is one of movement rather than
structure or mucosal health.
 It is particularly useful for disorders such as
spasmodic dysphonia and muscle tension
dysphonia, in which the voice problem is more
obvious during speech than in sustained vowels
and where rigid endoscopy has a limited role

Disadvantages:
The primary limitation of flexible endoscopy is that
light transport and magnification of the image are
inferior to those of rigid endoscopy.
In addition, many patients find the flexible examination
to be more invasive than the rigid examination.
The flexible technique carries the risks of nosebleed,
adverse reactions to the anesthetic, and vasovagal
reaction.

Technique of Flexible Laryngeal
Videoendoscopy:
The flexible endoscope is typically inserted after the
application of a topical anesthetic and a vasoconstrictor.
It can be passed through the inferior or middle meatus
of the nose.The higher path is preferred for examination
of the velopharyngeal port, but the paths are equivalent
for visualizing the larynx.
The examiner should raise the endoscope slightly as the
patient swallows to avoid triggering a cough or laryngeal
closure reflex, which can occur if the endoscope
touches the rising larynx during a swallow.

*Protocol:
Endoscopic parameters that require only continuous light
(as opposed to the xenon light of stroboscopy) include
laryngeal structure, arytenoid and vocal-fold motion, color
and quantity of mucus, vascularity, supraglottic activity or
compression, and deformation of vocal fold edges.
Laryngeal diadochokinesis is a useful measure, and
production rates of four to six syllables per second are
considered normal.
Examination of velopharyngeal function is indicated if
nasal emission or hypernasality is heard

If a flexible endoscope is used, several
other parameters can be assessed, including
repetitions of a short “ee” followed by a
quick sniff through the nose, a standard set
of phrases or sentences, and conversational
speech if voice quality during the
endoscopic examination is not consistent
with what was heard before it.

Protocol for Laryngeal Videoendoscopy (Continuous Light)
Rigid Endoscopy
Rest breathing
Deep breathing
Easy cough or throat clear
Laryngeal diadochokinesis “ee”
Laryngeal diadochokinesis “hee”
Flexible Endoscopy
All components of rigid exam
“ee” followed by a quick sniff (x3)
Whistling
Sentences and/or conversation as needed
Observation of velopharyngeal function during sustained sounds such as “ee” and “s”
Observation of velopharyngeal function during sentences loaded with nasal-oral contrasts

Laryngeal structure:
The valleculae, pyriform sinuses, epiglottis, aryepiglottic folds,
ventricular folds, and posterior glottic rim should be examined.
Lowered pitch during sustained “ee” widens the angle,allowing better
visualization of the valleculae.
Abnormalities and asymmetries of laryngeal structure are noted. An
omega-shaped epiglottis is a common variant in men, but it is rare in
women.
Signs of laryngeal irritation or possible laryngopharyngeal reflux are
noted; these primarily include edema, erythema, surface
irregularities, and lesions of the posterior larynx.

Arytenoid and vocal fold motion:
Movement and position of the arytenoids tell us about the
integrity of the cricoarytenoid joint and the recurrent
laryngeal nerve.
Arytenoids are typically described as mobile or immobile,
symmetric or asymmetric, and upright or rotated.
Immobility is further described by position: median,
paramedian, intermediate, or lateral.
 Motion of the arytenoid should be described separately
from movement of the posterior third of the vocal fold
because sometimes the arytenoid is mobile when the vocal
fold is fixed.
 Mobility is rated when patients phonate then breathe,
and during laryngeal diadochokinesis, cough, whistling,
and sniff.

Mucus:
Thickened mucus often adheres to the vocal fold edges or
superior surface. The presence of thick mucus generally
relates to a lack of hydration or to chronic irritation due to
mechanical trauma, smoking, or laryngopharyngeal reflux.
 Mucus pooling in the pyriform sinuses can indicate poor
laryngeal sensation, weak lateral pharyngeal walls, or
inefficient swallow.
Thickened mucus adhering to the vocal folds can be
misinterpret as a lesion or mask an abnormality. So,to allow
differentiation of mucus from underlying structures or
lesions, patients should be instructed to try to clear the
mucus by swallowing or gentle cough.

Vascularity:
The vocal folds are generally pearly white.A blush
throughout the tissue is considered erythema or
hyperemia.
If capillaries are visible, they are generally aligned
parallel with the free edge; horizontal vascularity is
cause for concern.
 Abnormally dilated and tortuous vessels, called
capillary ectasias or microvarices, might represent
areas of stiffness or risk for hemorrhage.
 Hemorrhage occurs when enough blood cells have
escaped from a vessel to lend a diffuse coloring to the
vocal fold. Post-hemorrhage vocal folds often appear
yellowbrown,similar to healing bruises in other areas.

*Assessment Using Stroboscopy
*A stroboscope is defined as “an instrument for determining the speed of
cyclic motion (as rotation or vibration) that causes the motion to appear
slowed or stopped.”
*Videostroboscopy is not slow-motion photography; it is an illusion of slow
motion. The illusion is possible because images linger on the retina for 0.2
second, and only five distinct images can be viewed per second. If more
than five per second are presented, the viewer perceives the images as
connected and sees the result as a smooth motion; this phenomenon is
referred to as Talbot's law.
*Videostroboscopy is used to assess vocal fold vibration patterns, mucosal
pliability, the underlying layered structure of the vocal folds, and the
undersurface of the vocal fold edges.
*It isparticularly valuable for assessing stiffness, scar, or submucosal injury;
detecting small vocal fold lesions; estimating the depth of invasion of a
tumor; identifying asymmetric mass or tension; or determining the
resumption of phonation after phonosurgery.

*Stroboscopic parameters include closure pattern, phase closure,
amplitude of vibration, mucosal wave, adynamic segments,
vertical closure level, symmetry, and regularity. Of these,closure
and mucosal wave are often considered key indicators of
function.
*The patient should produce a variety of pitches during the
examination. Bilateral and symmetric lengthening of the folds
during ascending pitch glides confirms that gross cricothyroid
muscle function is intact.
* High-pitch phonation is useful for highlighting midmembranous
edema and stiff or scarred segments along the edge.

Protocol for Laryngeal Videostroboscopy (Xenon Light)
Rigid Endoscope
* Sustained “ee” at patient's most comfortable pitch and loudness (MCPL) (several)
* “ee” on inhalation
* Glide midrange to high, sustaining the high note
* Glide midrange to low, sustaining the low note
* Quiet “ee”
* Loud “ee”
* Sustained “ee” at MCPL using locked mode
* Trial therapy or laryngeal manipulation as needed
Flexible Endoscope
* All components of rigid exam
* Consensus Auditory Perceptual Evaluation for Voice (CAPE-V) sentences:
* “The blue spot is on the key again.”
* “How hard did he hit him?”
* “We were away a year ago.”
* “We eat eggs every Easter.”
* “My mama makes lemon muffins.”
* “Peter will keep at the peak.”
* Singing tasks as necessary
* Conversation as necessary
* Humming or other trial therapy tasks as needed

*Closure pattern indicates how well the vocal
folds come together at midline during the
closed phase of the vibratory cycle.
Glottal closure and gap
patterns.
A, Complete closure;
B, posterior glottic gap;
C, anterior glottic gap;
D, spindle-shaped gap;
E, hourglass-shaped gap.

*Although “closure pattern” describes the extent of closure,
“phase closure” describes the duration of closure. During
vibration at MCPL, the glottis is typically open (opening, fully
open, or closing) for approximately two thirds of one vibratory
cycle and maximally closed for the remaining third.
*Mucosal wave is the vertical upheaval of the cover over the
body.
*Increased mucosal wave (i.e., it moves farther across the fold)
is observed when mucosa is abnormally pliable, such as in
polypoid degeneration or when there is increased subglottal air
pressure.
*decrease or absence of mucosal wave is seen with some
pathological conditions like scarring, or sulcus vocalis.
Incomplete glottic closure resulting from aging, atrophy, or
motion impairment can also lead to decrease or absence of
mucosal wave

A, Complete glottic closure. B, Maximum amplitude of vibration/excursion
*Amplitude of vibration refers to the fold's horizontal
excursion from midline. Normal is defined as approximately
one third of the width of the fold.
* Decreased amplitude is common in lesions such as firm
polyps, cysts, papilloma, carcinoma, Reinke's edema,
scarring, and hyperfunction.
*Increased amplitude may be a sign of decreased tonicity, as
observed in vocal-fold paresis or atrophy.

*Adynamic segments refers to nonvibrating areas of the vocal
fold (i.e., areas that have no mucosal wave and poor
amplitude of vibration).
*Symmetry is a timing parameter. It refers to the extent to
which the vocal folds appear as mirror images of each other
during vibration. The vocal folds should depart from midline
at the same time and arrive back at midline at the same time.
*Regularity (or periodicity) describes the degree to which
one phonatory cycle is similar in both amplitude and time to
the next phonatory cycle. Vibratory regularity is rated just
like symmetry, either by describing the percentage of time
that the vibration was regular or irregular or by describing
occurrences of irregularity. Aperiodic vibration gives rise to
acoustic noise, which can be perceived as roughness or
hoarseness.

*Vertical Closure Level:Whether the vocal folds meet on the
same plane is typically rated as on-plane or off-plane. Closure
is off-plane typically because of either neuromuscular
differences between the folds (paralysis or paresis) or laryngeal
trauma or surgery.

*Narrow-Band Imaging
*Narrow-band imaging (NBI) is a new endoscopic imaging
technique that employs the absorption characteristics of
light for the detailed analysis of mucosal and vascular
structures.
*NBI takes advantage of the differential absorption
characteristics of tissues. Blue light with its shorter
wavelength is better absorbed by hemoglobin.
*NBI shows promise for improving the yield of biopsies by
directing the examiner to the more “suspicious” areas, a
type of optical biopsy.
*It is currently available for gastroscopes including transnasal
esophagoscopes and flexible laryngoscopes. Clinicians are
beginning to explore the utility of NBI in laryngeal and
hypopharyngeal lesions

True vocal-fold scar at the anterior commissure.
A, White light; B, narrow-band imaging.

visual documentation and imaging of laryx.pptx

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