eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Sulcus Vocalis: Treatment

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

Treatment

Medical Therapy

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 eMedicine 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.

Surgical Therapy

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.3

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."4 Paniello (2008) reported good results in 2 patients treated specifically for sulcus vocalis with this approach.5

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.

Preoperative Details

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 (see Image 2) and videostroboscopy (see Image 3), 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.

Intraoperative Details

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.

Postoperative Details

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.

Follow-up

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.

Complications

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.

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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