eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Sulcus Vocalis

Author: John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
Coauthor(s): Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Contributor Information and Disclosures

Updated: Nov 17, 2008

Introduction

The term sulcus vocalis is used specifically to describe a groove or infolding of mucosa along the surface of the vocal fold. In the area of the sulcus, the mucosa is scarred down to the underlying vocal ligament, giving it a retracted appearance.

Essentially, no differences exist between vocal fold scarring where an identifiable sulcus is present and scarring where an identifiable sulcus is not present. In either case, an alteration in the normal physiology of vocal fold vibration exists, which affects voice production. Therefore, this chapter will focus on vocal fold scarring and its effect on vocal physiology.

Most clinicians agree that presentation of sulcus vocalis is hoarseness, vocal fatigue, voice weakness, and increased effort. However, clinicians may disagree on terminology, diagnosis, and treatment of this disorder. Certainly, widespread acceptance of videostroboscopy has allowed more clinicians to recognize the disorder. This has spurred new interest in its diagnosis and treatment.

History of the Procedure

Patients may experience hoarseness but more often have symptoms of glottal insufficiency, including fatigue, poor volume, and poor projection. However, the voice may be normal with more subtle symptoms (eg, fatigue, decreased vocal range with singing).

Problem

The term sulcus vocalis is used to describe a depression or groove in the surface of vocal fold mucosa that is typically found on the leading edge of the vibratory surface. Along the sulcus, the mucosal cover is scarred down to the underlying vocal ligament and therefore is tethered. A linear sulcus, nearly the length of the true vocal fold, can be seen in Image 1.

A mucosal bridge is a variation on the simple sulcus and is formed when 2 parallel sulci simultaneously appear on the medial and superior surface of the true vocal fold. This creates an area of normal-appearing mucosa between 2 mucosal defects. These lesions are more difficult to treat than single sulci but fortunately are very rare.

Frequency

The incidence of sulcus vocalis is impossible to determine due to variation in presentation and diagnosis. Most sulci are undiagnosed because of subclinical symptoms, lack of clinician awareness, and difficulty in identification due to limited availability of laryngeal videostroboscopy. In a study of autopsy specimens by Nakayama et al, sulci were identified in 20% of specimens.1

Etiology

Sulcus vocalis may be congenital or secondary to vocal trauma, infection, degeneration of benign lesions, or surgery. In addition, Bouchayer et al proposed a relationship with ruptured congenital epidermoid cysts and also suggested that the disorder may demonstrate familial patterns.2 Typically, patients with congenital sulci have a lifelong history of disordered voice.

Presence of parallel sulci associated with a mucosal bridge is consistent with ruptured cyst etiology. Surgical causes include overresection of the superficial layer of the lamina propria, resulting in remucosalization over the deficient area and damage to the vocal ligament and deep layers of the lamina propria. Nonsurgical causes include untreated benign lesions, chronic vocal abuse, and repeated intracordal hemorrhage. Microvascular lesions (ie, varices, capillary ectasias) also may result in scarring secondary to hemorrhage and fibrosis.

Pathophysiology

A defect in the medial surface of the true vocal fold along the sulcus may produce a glottic gap. More importantly, the cover may fibrose to the vocal ligament and result in a diminished or absent vocal mucosal wave. This decreased pliability restricts the Bernoulli and myoelastic effects, whereby transglottic airflow medializes the leading edge of the vocal fold. The overall effect is usually a higher fundamental frequency with significantly reduced harmonics and harsher voice quality.

Presentation

Patients experience hoarseness and often have symptoms and signs of glottal insufficiency, including poor volume, poor projection, and vocal fatigue. On initial interview, the voice may be hoarse and breathy or acceptable, but most patients have an overall decrease in vocal performance.

Examination of the true vocal fold reveals a linear depression or an area of incomplete closure. Videostroboscopy reveals an area of decreased mucosal wave corresponding to the sulcus and more clearly demonstrates the associated incomplete closure.

Relevant Anatomy

Awareness of the body-cover principle of vocal fold vibration is essential to the understanding of sulcus vocalis. The vocal fold is composed of a muscle covered by a free mucosal edge that vibrates and can be separated into discrete layers in which various types of pathology may develop. Each layer has distinct mechanical properties and can be differentiated by the concentration of elastin and collagen fibers that run parallel to the leading edge.

Histologically, the vocal fold is a complex structure. The delicate arrangement of extracellular matrix proteins within the lamina propria permits passive movement of the vocal cover over the vocal ligament and muscle, or body. This results in formation of the mucosal wave as air is passed through the glottis as a release of building subglottic pressure. Violation of deeper layers of the lamina propria and vocal ligament, as was once common with stripping procedures, is now known to be associated with scar and sulcus formation.

More on Sulcus Vocalis

Overview: Sulcus Vocalis
Workup: Sulcus Vocalis
Treatment: Sulcus Vocalis
Follow-up: Sulcus Vocalis
Multimedia: Sulcus Vocalis
References
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References

  1. Nakayama M, Ford CN, Brandenburg JH, et al. Sulcus vocalis in laryngeal cancer: a histopathologic study. Laryngoscope. Jan 1994;104(1 Pt 1):16-24. [Medline].

  2. Bouchayer M, Cornut G, Witzig E, et al. Epidermoid cysts, sulci, and mucosal bridges of the true vocal cord: a report of 157 cases. Laryngoscope. Sep 1985;95(9 Pt 1):1087-94. [Medline].

  3. Archer SM, Banks ER. Intracordal injection of autologous fat for augmentation of the mucosally damaged canine vocal fold: a long-term histologic study. 2nd World Congress on Laryngeal Cancer. 1994.

  4. Gray SD, Bielamowicz SA, Titze IR, et al. Experimental approaches to vocal fold alteration: introduction to the minithyrotomy. Ann Otol Rhinol Laryngol. Jan 1999;108(1):1-9. [Medline].

  5. Paniello RC, Sulica L, Khosla SM, et al. Clinical experience with Gray's minithyrotomy procedure. Ann Otol Rhinol Laryngol. Jun 2008;117(6):437-42. [Medline].

  6. Sataloff RT, Spiegel JR, Hawkshaw M, et al. Autologous fat implantation for vocal fold scar: a preliminary report. J Voice. Jun 1997;11(2):238-46. [Medline].

  7. Chan RW, Titze IR. Viscosities of implantable biomaterials in vocal fold augmentation surgery. Laryngoscope. May 1998;108(5):725-31. [Medline].

  8. Dailey SH, Ford CN. Surgical management of sulcus vocalis and vocal fold scarring. Otolaryngol Clin North Am. Feb 2006;39(1):23-42. [Medline].

  9. Ford CN, Inagi K, Khidr A, et al. Sulcus vocalis: a rational analytical approach to diagnosis and management. Ann Otol Rhinol Laryngol. Mar 1996;105(3):189-200. [Medline].

  10. Gray S. Basement membrane zone injury in vocal nodules. Vocal fold phyisiology. 1991.

  11. Gray SD, Bielamowicz SA, Titze IR, et al. Experimental approaches to vocal fold alteration: introduction to the minithyrotomy. Ann Otol Rhinol Laryngol. Jan 1999;108(1):1-9. [Medline].

  12. Hammond TH, Zhou R, Hammond EH, et al. The intermediate layer: a morphologic study of the elastin and hyaluronic acid constituents of normal human vocal folds. J Voice. Mar 1997;11(1):59-66. [Medline].

  13. Hsiung MW, Pai L. Autogenous fat injection for glottic insufficiency: analysis of 101 cases and correlation with patients' self-assessment. Acta Otolaryngol. Feb 2006;126(2):191-6. [Medline].

  14. Pontes P, Behlau M. Treatment of sulcus vocalis: auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. J Voice. Dec 1993;7(4):365-76. [Medline].

  15. Titze IR. The physics of small-amplitude oscillation of the vocal folds. J Acoust Soc Am. Apr 1988;83(4):1536-52. [Medline].

  16. Tsunoda K, Kondou K, Kaga K, et al. Autologous transplantation of fascia into the vocal fold: long-term result of type-1 transplantation and the future. Laryngoscope. Dec 2005;115(12 Pt 2 Suppl 108):1-10. [Medline].

  17. Varela DG, Grellet M. [Vocal fold superficial layer of lamina propria histology after the position of mucosa pediculated flap: canine experimental study]. Braz J Otorhinolaryngol. May-Jun 2005;71(3):318-24. [Medline].

  18. Yanagihara N. Significance of harmonic changes and noise components in hoarseness. J Speech Hear Res. Sep 1967;10(3):531-41. [Medline].

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Further Reading

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Keywords

sulcus vocalis, vocal fold scarring, benign voice disorders, mucosal scarring, hoarseness, voice fatigue, loss of range, vocal fold groove

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Contributor Information and Disclosures

Author

John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Robert Ossoff, DMD, MD, MS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Chest Physicians, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, Sigma Xi, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine
Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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