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case presentation


    36 year old female mother of two with a 4-year history of intermittent hoarseness. Nonsmoker, generally very healthy, regular exercise. Very talkative person with outgoing personality and work which requires constant talking both to groups and on a one-to-one basis. Reports that her family is also very loud in general. Gradual deterioration of voice over the past few years. Some environmental allergies.

Initial examination

    On examination the patient displays moderate dysphonia and a mild strained quality in normal speech. During pitch-range exercises, voicing is intermittent but overall frequency range relatively normal. Preoperative audio clip below illustrates these traits.

    Preoperative reading of the "Three Bears passage". Note the moderate dysphonia and occasional pitch breaks, especially during phonation at higher frequencies. compare this to the postoperative audio sample

    Videostroboscopic examination reveals bilateral vocal cord masses, probably nodules, which impedes normal voicing. The vocal cords open and close normally in prephonatory adduction as seen in the preoperative stills) below. However, closure is not complete, due to the bilateral mass lesions.

    Preoperative laryngoscope images. Left: maximally closed glottis just before phonation. Right: maximally open glottis on inhalation. Note the incomplete closure and characteristic hourglass shape due to the vocal fold masses. Click here to compare these images directly, and against postoperative result.

    Stroboscopic viewing of the moving vocal folds shows vocal cord motion inhibited by the presence of the masses. In the first video clip below, we see phonation in the lower end of the pitch range. Due to the thickening of the vocal folds required to produce low pitches, the nodules do not overly interfere with phonation. In the second preoperative video clip, we see the pitch breaking and hoarseness noted in the "baby bear" section of the audio recording above.

    Preoperative Strobed Video recording. This first clip is of low frequency phonation.
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    Preoperative Strobed Video recording. This second preoperative clip illustrates the pitch-breaking and hoarseness present particularly at high pitches.


    After about 6 months of voice therapy to try to relieve the nodules by non-operative techniques, it was decided to intervene surgically and remove the nodules using laryngeal microsurgical techniques. The patient was anaesthetised, and the nodules removed in a micro direct laryngoscopic procedure. The medial edge of the vocal cords was smoothed by cold dissection of the nodules, which were noticably larger in their inferior extent than seen in the intraoperative photographs below.

    Intraoperative images. Left: vocal cords just before excision of nodules. Right: immediately after microsurgical removal of nodules.

Postoperative Examination

    The postoperative audio sample below speaks for itself when compared to the preoperative audio sample. This sample is from a ten-day followup examination. The patient reports that she is able to sing again, and that her voice seems almost back to normal. The sample clearly shows that removal of the nodules has eliminated the pitch breaks which were occurring, and also shows an increased ease of phonation.


    Postoperative audio recording. Compare this to the preop audio sample. Note the disappearance of pitch breaks and strained quality of her voice.


The postoperative examination shows that despite some residual scarring from the surgery, normal vocal fold motion is restored. The still images below illustrate the residual scarring, while the video clip show the relative unimportance of such minimal scarring. Click here to compare these images directly, and against preoperative examination.

Ten-day postoperative laryngoscope images. Left: Open glottis. Right: closed glottis. We see that the vocal fold edge is not completely smooth due to scarring from the surgical intervention, but that the nodules have been successfully removed.

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Postoperative Strobed Video recording. Some excess mucous present. Note the signs of scarring from surgery: the right fold (left on the video) has a mucosal wave which does not travel parallel to the medial edge of the fold, and the vocal fold medial edge is also not perfectly straight. This does not seem to impede vocal cord functioning to any important extent.

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