Sulcus Vocalis Treatment & Management
- Author: John Schweinfurth, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Anatomic change in the vocal fold (eg, sulcus vocalis) is difficult to treat medically. Any intercurrent medical conditions affecting the voice (eg, reflux laryngitis, allergic rhinitis) are evaluated and treated. Prior to considering surgical therapy, all known sources of mechanical trauma are maximally reduced to determine reversibility and hopefully prevent a postoperative recurrence. This is accomplished in part by medical and speech therapy to reduce vocal trauma through improved phonatory technique and vocal hygiene.
The primary goal of speech therapy is to improve vocal efficiency. The method most commonly employed is direct speech therapy, which is covered in the Medscape Reference article Voice Therapy. When voice therapy is combined with external measures (eg, amplification) and behavioral alterations (eg, scheduling vocal rest periods), vocal fatigue may dissipate.
Surgery is reserved for unresolving lesions that have resulted in persistent troublesome dysphonia.
Patients with sulcus vocalis may complain of vocal insufficiency, loss of quality, or both. When low volume and loss of projection are major complaints, medialization of the scarred vocal fold may significantly improve vocal performance while decreasing effort and fatigue.
Medialization alone may not significantly impact vocal quality. An attempt to reconstitute the lamina propria may be considered for patients who have adequate volume but poor vocal quality.
Current opinion holds that placing a biocompatible material between the vocal ligament and cover or within the layers of the lamina propria could compensate for lost tissue and restore sliding movement of the mucosal cover. This additional layer also may prevent fibroblast migration from deeper layers and further scar formation. A thick scar band associated with the sulcus may be removed through a microflap approach. However, this maneuver carries the risk of further fold thinning. The ideal implant material assumes the function of the intermediate layer of the lamina propria, which is composed of elastin, hyaluronic acid, and fibromodulin. Implant material is placed to augment the infraglottics and free edge of the vocal fold. Phonation threshold pressure (ie, amount of pressure required to initiate voice) is decreased by improved closure, increased fold thickness, and lower viscous damping (ie, tissue inertia). Therefore, the ideal implant has low viscosity and resorption and is injectable.
Injectable collagen gained interest early because of its ability to soften scar tissue when used in the face. Bovine collagen has a comparatively high resorption rate and a moderate risk of local immune reaction. Autologous collagen has good short-term results, but information about long-term survival is limited. In addition, skin must be harvested at a separate sitting for autologous collagen extraction, and processing is relatively lengthy and expensive. When normal lamina propria reproduction is the goal of implantation, fat is the available material most similar in viscosity (4 pascal seconds [Pa-s]) to the lamina propria. In contrast, collagen has a much higher viscosity (10 Pa-s).
Autologous fat probably is the best augmentation material currently in widespread use. More forgiving placement of autologous fat within the larger muscle bed is possible, and longevity has improved through development of viable adipocytes. Archer and Banks demonstrated maintenance of viable adipocytes and bulk for up to 1 year in an animal model.
Fat may be implanted into the vocal fold through an endoscopic approach but may also be implanted through a surgically created window in the thyroid cartilage, or "minithyrotomy." Paniello (2008) reported good results in 2 patients treated specifically for sulcus vocalis with this approach.
Injectable hyaluronic acid may also have an application in the treatment of patients with sulcus vocalis. Because hyaluronic acid makes up the gel-like space of the superficial lamina propria, replacing it has long been considered the holy grail of therapy for vocal scarring. Although the usefulness of hyaluronic acid is unknown, early reports suggest that maintaining sufficient volume of material in the desired location is problematic. Studies into the use of this material are ongoing.
A study by Hwang et al suggested that pulsed dye lasers can effectively be used to treat sulcus vocalis. Each treatment in the study, which involved 25 patients with the condition, consisted of 60-100 laser pulses (0.75 Joules per pulse) on each vocal fold. The procedures appeared to decrease vocal fold stiffness, improve mucosal wave properties, and reduce dysphonia. Moreover, in most patients, improvement was demonstrated in several postoperative voice analysis indices.
The aforementioned study by Lee et al, which indicated that epithelial pathology plays an important part in sulcus vocalis, suggested that surgical treatment should involve the removal of pathologic epithelium, as a means of treating inflammation.
Surgical candidates must be willing to postpone speaking and singing engagements for at least 3 months postoperatively. Patients presenting with dysphonia are evaluated by indirect laryngoscopy (as seen in the image below) and videostroboscopy (as seen in the image below), with particular attention to vocal fold mobility; glottic closure; and the presence, amplitude, and symmetry of the mucosal wave.
Diagnostic laryngoscopy may be necessary prior to invasive procedures aimed at altering laryngeal anatomy in order to have a more complete understanding of vocal fold pathology and potential for surgical treatment. Specifically, the ability of the surgeon to adequately expose the larynx may affect the surgical approach chosen. The area of vocal scarring may be more closely estimated by palpation. Some surgeons employ a diagnostic infusion of saline under the mucosa to assess the feasibility of injecting or implanting biocompatible material.
Bring the microscope into position after the larynx is adequately exposed. Remove obvious scar tissue and bands of fibrosis whenever possible, preferably through a microflap approach. Endoscopic or transcutaneous injection is the most convenient method of implant delivery, but anecdotal reports suggest that sufficient bulk cannot be obtained through injection alone; passage through a needle barrel is too traumatic to the adipocytes; and the implants may extrude out of the injection site. On the other hand, implanted fat tends to migrate superiorly in the pocket. The authors' current technique is to harvest fat via a large 8-mm liposuction cannula and inject it into the thyroarytenoid muscle with a Breunig syringe. Anecdotal reports support rinsing harvested fat in insulin to support adipocyte cell membrane stabilization. A moderate decrease in volume in the early postoperative period should be expected. Therefore, overcorrect the vocal fold at the time of surgery.
Patients are placed on strict voice rest for 2 weeks following microflap surgery. Patients with more extensive dissections may be placed on a short course of corticosteroids. All patients receive antibiotics for 7 days and a mild narcotic for pain relief. Patients with symptoms or findings of laryngopharyngeal reflux are medically treated with a proton pump-inhibiting agent.
Patients are re-examined at 2, 4, 8, and 12 weeks postoperatively. At the 2-week postoperative visit, videostroboscopy is performed, and the patient resumes therapy with the speech pathologist. Gradual return to voice use over the first few weeks is recommended, increasing by 5-minute intervals twice daily. Singers may begin work with the vocal pedagogue at 1 month but are cautioned to back off if they feel any discomfort or strain. Most patients can expect to see 90% of the functional surgical result at about 3 months.
Surgical complications are related to laryngoscopy, vocal cord incision, and implantation of material for medialization. Complications of laryngoscopy include damage to or avulsion of teeth; oral mucosal laceration; and pressure damage to the tongue, including numbness or altered taste. Any vocal fold incision can result in further scar formation with recurrence of the sulcus.
Outcome and Prognosis
In 2 studies, microsurgical techniques were used on 30 patients with pathologic sulcus. Voice improvement was reported in the majority of subjects using objective measures. Using fat implantation methods, Sataloff et al described voice improvement and limited return of mucosal wave. Most patients can expect significant voice improvement from either technique, but results are not equal to premorbid conditions in most cases. Additionally, insufficient data exists on the longevity of improvement.
Future and Controversies
Future injectable materials may more closely simulate composition of the intermediate layer and hyaluronic acid, but consistent placement and long-term positional stability remain difficult. Certainly, the best way to treat scarring is to prevent it. Improperly performed or timed surgical intervention can result in irreversible dysfunction and dysphonia. Conservative treatment should be exhausted before surgical intervention is considered, which should be based on the modern concept of vocal fold microanatomy and histology. Use of microflap techniques avoids a raw mucosal surface that heals by secondary intention and may result in a sulcus.
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