Repeated analysis of cinephotographic and cinefluorographic studies, correlated with clinical observations, has helped elucidate the causes of contact ulcers. Habitual throat clearing, excessive glottic attack in initiation of speech, and, most important, acid regurgitation secondary to hiatal hernia are the causal factors of contact ulcers. Contact granulomas produced by intubation trauma and other granulomas are compared and discussed. The successful treatment of contact ulcers and granulomas is dependent on elimination of vocal abuse, cessation of throat clearing, and control of the factors that cause the irritation and throat clearing.CONTACT ulcers and granulomas of the larynx are relatively uncommon but well-recognized clinical and pathologic entities. Jackson' first used the term "contact ulcer" to describe the unilateral or bilateral ulceration over the vocal processus of the arytenoid, with or without granulations. He and most other authors attributed the causative factors to mechanical traurna.>"Contributions to a better understanding of the several mechansims of production and approaches to treatment were made by Peacher and Hollnger,t von Leden

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Coughing and throat clearing are vocally abusive activities that can be directly related to laryngeal disease. Methods of therapy include advising the patient to avoid or eliminate these activities, although the authors have found that few patients benefit from such suggestions. The action of coughing and throat clearing has been examined by means of indirect laryngoscopy and high-speed cinematography, and the stages of the cough from complete constriction of the folds to violent abduction are reviewed. Although the cough reflex is a natural protective mechanism that at times must be activated because of obstruction of the air tract, continual coughing and throat clearing frequently have a significant nonessential component. The actions may be due to an overawareness of secretions in the larynx, the fruitless use of coughing or throat clearing to eliminate pain or discomfort, or unconscious habit. Methods to treat this type of cough or throat clearing are explored, with special emphasis on the “silent cough,” a technique the authors devised as a substitute for unnecessary coughing or throat clearing. Case reports are presented to illustrate this method in therapy.

A functional speech mechanism was created during laryngectomy in five patients. The method used involved construction of a shunt between the esophagus inferior to the superior esophageal constrictor and membranous portion of the trachea. Speech produced with the tracheo-esophageal shunt was highly intelligible and is functional after the nasal gastric tube is removed. Speech characteristics resemble closely those of superior esophageal speech. Pitch, intensity, and intelligibility were comparable to superior alaryngeal speech, and cinefluorographic analysis revealed that the pseudoglottis frequently used by esophageal speakers also was used by speakers with tracheo-esophageal shunts. Late stenosis has been the primary disadvantage; a new method to eliminate closure is being investigated. Since the tracheo-esophageal shunt can be used effectively in communication, further patient application and construction modifications are warranted.

Velopharyngeal closure may be observed directly with a laryngeal telescope 6 mm in diameter. The speech sample used during the endoscopic examination should include several repetitions of a plosive consonant to insure sustained closure. Thirty-four normal subjects were observed, and the percentage of occurrence in four categories of velar and lateral wall approximation was calculated and categorized. To confirm the observations, cineradiographic (lateral and submentovertical projections) and telescopic observations were compared. Parallel observations were made for both methods. The procedure for using the telescope is explained, and issues relating to interpretation of telescopic observations are discussed.