Sulcus Mucosal Slicing Tecnique
Sulcus Mucosal Slicing Tecnique
Sulcus Mucosal Slicing Tecnique
Keywords
dysphonia, slicing technique, sulcus striae, sulcus vocalis
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sulcus mucosal slicing technique Pontes and Behlau 513
Table 1 Classification of sulcus according to Pontes et al. [19], considering other minor structural alterations of the larynx
Minor structural alterations Undifferentiated
of vocal fold cover Differentiated Sulcus Occult
Striae Minor
Major
Pocket
Deep
Epidermoid cysts Superficial
Fistulized
Mucosal bridge
Laryngeal microdiaphragm
Vascular dysgenesia
The functional impact of a minor structural change Sulcus striae major is visualized as a mucosal depression
depends on its morphology and on the individual vocal similar to a groove or a furrow due to the relative distance
profile. There is not a direct and simple correlation between its lips, creating a superior and inferior margin,
between morphology and functional outcome. Besides the latter usually rigid (Figs 3 and 4). The vocal impact is
the morphological configuration, axiological factors, related to the depth of the sulcus, which produces a
personality aspects (extraversion trait), vocal usage, occu- distorted mucosal wave that can even be absent. Voice
pational demands and vocal hygiene habits may trigger is rough, tense, high-pitched and usually disagreeable,
the dysphonia. Vocal deviations, besides vocal fatigue sometimes with a diplophonic component; breathiness
and effort to phonate, can include high-pitched voice, can be severe and even produce phonatory breaks. Con-
instability, roughness, breathiness and strain. trary to the previously presented variant, the sulcus striae
major rarely produces secondary lesions due to lack of
enough glottic closure.
Sulcus classification
The morphological classification of sulcus adopted by us The treatment of this alteration has to consider its main
is as follows: occult sulcus, sulcus striae (or vergeture) and functional consequence. For discrete cases, vocal reha-
sulcus pocket. bilitation can lead to stabilization; for severe cases
(reduced or absent mucosal wave and moderate to large
Occult sulcus glottic chinks), surgery is usually applied.
This alteration is solely identified by laryngostroboscopy
during phonation through observation of the mucosal Sulcus pocket
wave formation. The impact on spoken voice is minimal Previously named open cyst or sulcus vocalis [6], a sulcus
and, if present, restricted to vocal range. Dysphonia can pocket corresponds to a real cavity in the vocal fold, in
be triggered when vocal loading is enhanced. which the lips still preserve contact [21] (Figs 5 and 6). Its
presentation is usually like a mucosal bump, similar to a
Sulcus striae cyst (a frequent misdiagnosis), as the mucosal opening is
The term striae (vergeture) was proposed by Bouchayer
et al. [6] in order to characterize vocal fold depressions Figure 1 Schematic drawing of a sulcus stria minor
similar to skin marks (wrinkles). However, we propose
two variants, the minor and major ones, according to the
distance between the depression lips.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
514 Laryngology and bronchoesophagology
Figure 2 Sulcus stria minor (arrow), under laryngoscopic vision, Figure 4 Sulcus stria major (arrow), under laryngoscopic vision,
during inspiration during inspiration
rarely seen in routine examinations. Its mucosal wave has cation of Pontes et al. [19]. Ford et al. [11] provided a
a better vibratory pattern than the striae sulcus. Glottic categorization of three types of sulcus: type I, named
closure can be complete, irregular or with double chink. physiological sulcus, is a depression that does not reach
Secondary lesions, such as polyps, contralateral reactions, the vocal ligament; type II is a full-length musculomem-
leukoplakias and chronic laryngitis are frequently associ- branous vocal fold depression, extending down to the
ated. Monochorditis is usually a sign of sulcus pocket vocal ligament or further; and type III is a deep focal
presence at vocal fold level. Voice is usually low-pitched indentation of the vocal fold that does not involve the
due to the increase of the vocal fold mass. Dysphonia whole length of the focal fold.
degree can vary and be present in a fluctuating fashion;
inflammatory episodes are the main cause of vocal varia- The surgery is an anatomical procedure with a functional
bility. Vocal rehabilitation is suggested to improve muco- goal. Therefore, a morphologically based classification is
sal vibration, to reduce secondary lesions and to achieve a beneficial to design and plan the surgery.
differential diagnosis with vocal fold nodules. Surgery for
sulcus pocket is the deepithelization of the cavity.
Management of sulcus striae
Many authors have classified the sulcus with different Several surgical techniques to treat sulcus striae have
criteria, and therefore there is not a correspondence been proposed, with variable results: sulcus resection
among them. Table 2 [22,23] presents these classifi- [24], vocal fold augumentation volume through endo-
cations distributed similarly to the anatomical classifi- scopic techniques using collagen [25], fat [26,27,28],
Figure 3 Schematic drawing of a sulcus striae major Figure 5 Schematic drawing of sulcus pocket
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sulcus mucosal slicing technique Pontes and Behlau 515
Figure 6 Interior exposure of the sulcus pocket with spatula in Figure 7 Sulcus striae major: endoscopic approach
microlaryngoscopy
muscle fascia implantation [29], external medialization tricular face tissue to participate in the sound source.
via thyroplasty type I [30,31], and laryngoplasty with With this procedure, a triple result can be obtained:
tissue transposition [32,33]. pliability of the mucosa, vibratory tecidual structure
and reduction of glottic chink.
In cases with no mucosal wave and cordal vibration (one
mass regimen), with large glottic chinks, the above-men- The main technical challenges are listed below:
tioned techniques are insufficient to produce a better
vocal quality and/or provide vocal endurance. Vocal fold (1) Visibility (Fig. 7): adequate visual surgical condition
medialization or sulculectomy will not be able to provide to perform endoscopic approach surgery.
mucosal pliability and may even introduce more mech- (2) Soft tissue identification (Fig. 8): longitudinal
anical resistance to phonate. Therefore, surgical inter- incision at the vocal fold vestibular face away from
ventions may have to be aggressive, as the tissue pres- the edge, as close as possible to the laryngeal ven-
ervation rule may not apply here due to the fact that these tricle, including the available soft tissue.
patients do not show a normal configuration of the multi- (3) Main flap procedure (Fig. 9): out from the longi-
layered mucosal structure. In these cases, our surgery tudinal incision, a tissue flap inferiorly based has to
option is using the slicing technique [34]. be created with a 2-mm depth from the sulcus
inferior margin; the tissue flap has to be thick to
preserve vascular properties and avoid necrosis; in
Technical challenges of the slicing mucosa all cases vocal ligament will be partially or totally
technique included; in a few cases some portion of the thyr-
There are many technical challenges of the slicing oarytenoid muscle will take part of the flap.
mucosa technique, some related to the nature of the (4) Number of secondary flaps: a minimum of four
alteration and others to the surgeon’s skills. The goal different length incisions, perpendicular from the
of the surgery is to interrupt the longitudinal tension free edge of the main flap (counter-incisions) have to
produced by the presence of the sulcus, as well as to be created in order to produce at least three small
promote mucosal vibration by bringing the pliable ven- flaps.
Table 2 Pontes et al. [19] classification of vocal sulcus and similar classifications
Classification
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
516 Laryngology and bronchoesophagology
Figure 8 Longitudinal incision at the left vocal fold Figure 10 Secondary flaps procedure: first incision
(5) Secondary flaps procedure (Figs 10–13): a progress- frequency should be avoided, when possible. No
ive and alternate approach has to be applied in order sutures are necessary.
to avoid retraction and loss of control of surgical site. (8) Positioning of secondary flaps: the slicing movement
Usually three to five small counter-incisions have to will bring about the flaps into an adequate position.
be done to obtain three to four mucosal flaps. The No manipulation is done.
inferior margin of the sulcus has to be surpassed in (9) Bilateral approach (Fig. 16): both sides need to be
order to interrupt the tension line. approached at the same surgical timing; even
(6) Size of secondary flaps (Fig. 14): the surgeon must though there may be asymmetrical impairment.
be cautious in order to produce the flaps with This procedure will favor vocal rehabilitation. In
different depth to avoid reestablishing the tensional three cases of our series where the bilateral approach
scar line. was not respected, results were highly limited.
(7) Hemostasis (Fig. 15): Hemostasis is generally easily (10) Postsurgical complication: synechiae and granulo-
controlled with adrenalin-embedded cotton; radio- mas are rarely seen; synechiae are usually soft and
Figure 9 Main flap procedure Figure 11 Secondary flaps procedure: four small
counter-incisions
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sulcus mucosal slicing technique Pontes and Behlau 517
Figure 12 Secondary flaps procedure: progressive approach Figure 14 Secondary flaps procedure: unilateral final view
Figure 13 Secondary flaps procedure: surpassing inferior Figure 15 Hemostasis: adrenalin-embedded cotton
margin
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
518 Laryngology and bronchoesophagology
Figure 16 Both sides approached: final view logical cases (Brazilian data)] [38–40]. It is interesting to
point out that the number of coping strategies [41] used to
deal with the problem can be very high, almost 40% higher
than the average voice patient, meaning that the patient
tries to cope with it in as many ways as he/she is able to.
Voice after surgery can be even worse than prior to it. The
patient needs to be fully informed and prepared for what
he/she will face. Self-assessment protocols can show even
higher deviated scores, even though acoustic, aerodynamic
and stroboscopic data may have improved [37], demanding
a careful long-term follow-up by a multidisciplinary team.
(a and b) Presurgical inspiratory and phonatory images. (c and d) Postsurgical inspiratory and phonatory images.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sulcus mucosal slicing technique Pontes and Behlau 519
involvement and general muscle hyperfunctioning. Two 6 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 1985;
strategies can be initially used to activate the surgical site: 95:1087–1094.
nasal (‘m’ and ‘n’) or voiced fricative sounds (‘v’ or ‘z’). A 7 Lindestad PA, Hertegård S. Spindle-shaped glottal insufficiency with and
clear short-unit production is the goal for the first month without sulcus vocalis: a retrospective study. Ann Otol Rhinol Laryngol 1994;
103:547–553.
of rehabilitation (usually 10 units, three subsequent
8 Sato K, Hirano M. Electron microscopic investigation of sulcus vocalis. Ann
series, 10 times a day). In cases when the ventricular Otol Rhinol Laryngol 1998; 107:56–60.
fold interference persists, inhalation phonation and 9 Remacle M, Lawson G, Degols JC, et al. Microsurgery of sulcus vergeture
yawn–sigh techniques can be effective [34]. Fatigue is with carbon dioxide laser and injectable collagen. Ann Otol Rhinol Laryngol
2000; 109:141–148.
a frequent complaint at this stage; patients usually report 10 Dailey SH, Ford CN. Surgical management of sulcus vocalis and vocal fold
having to work too hard to phonate. Three to four sessions scarring. Otolaryngol Clin North Am 2006; 39:23–42.
a week are needed for the first month until voicing is An excellent article on surgical procedures to manage sulcus vocalis.
11 Ford CN, Inagi K, Khidr A, et al. Sulcus vocalis: a rational analytical approach to
achieved. The second goal is to extend voicing to speech diagnosis and management. Ann Otol Rhinol Laryngol 1996; 105:189–200.
segments, using controlled phonetic environment sylla- 12 Martins RHG, Silva R, Ferreira DM, Dias NH. Sulcus vocalis: possible genetic
bles, words and phrases. A visual monitoring system, such pathology. Report of four familiar cases (in Portuguese). Rev Bras Otorrino-
laringol 2007; 73–74.
as real-time spectrographic trace (GRAM program,
13 Cakir ZA, Yigit O, Kocak I, et al. Sulcus vocalis in monozygotic twins. Auris
Visualization Software; FonoView Software, CTS Infor- Nasus Larynx 2010; 37:255–257.
matica) is of great help in aiding the patient to control 14 Van Caneghan D. The etiology of the vocal cord furrow (in French). Ann Mal
voicing (visual–vocal loop). The third goal is to improve Oreille Larynx Nez Pharynx 1928; 43:121–130.
mucosal flexibility by vocal fold elongation and short- 15 Priston J. The evolution of an epidermoid cyst during vocal mutation (in
Portuguese). In: Behlau M, editor. O Melhor Que Vi e Ouvi Atualização
ening exercises (gliding with nasal and voiced fricative em Laringologia e Voz. Revinter: Rio de Janeiro; 1998. pp. 114–120.
sounds). At this moment lip and tongue trills can be 16 Hirano M, Yoshida T, Tanaka S, Hibi S. Sulcus vocalis: functional aspects.
introduced. Semi-occluded vocal tract exercises (reduced Ann Otol Rhinol Laryngol 1990; 99:679–683.
diameter straws or larger glass tubes) can be effective in 17 Giovanni A, Chanteret C, Lagier A. Sulcus vocalis: a review. European
archives of oto-rhino-laryngology: official journal of the European Federation
dealing with vocal fatigue and promoting vocal endur- of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German
ance. Monitoring fundamental frequency and targeting a Society for Oto-Rhino-Laryngology. Head Neck Surg 2007; 264:337–344.
Excellent review paper with the most important information on sulcus.
specific low-frequency range may be necessary.
18 Luchsinger R, Arnold GE. Vocal disorders of constitutional origin: dysplastic
dysphonia. Voice–speech–language. Belmont, California: Wadsworth Pub-
Therapy follows an intensive regimen generally up to lishing; 1965. pp. 167–175.
4 months, when once a week or every fortnight dose can 19 Pontes P, Behlau M, Gonçalves MIR. Minor structural alterations of the larynx:
basic aspects (in Portuguese). Acta AWHO 1994; 2:175–185.
be applied. In some cases, monthly follow-up and
20 De Biase NG, Pontes PA. Blood vessels of vocal folds: a videolaryngoscopic
reinforcement sessions are used for a period of a year study. Arch Otolaryngol Head Neck Surg 2008; 134:720–724.
after surgery. 21 Pontes P, Goncalves M, Behlau M. Vocal cover minor structural alterations:
diagnostic errors. Phonoscope 1999; 2:175–185.
22 Nakayama M, Ford CN, Brandenburg JH, Bless DM. Sulcus vocalis in
Conclusion laryngeal cancer: a histopathologic study. Laryngoscope 1994; 104:16–24.
The slicing technique surgery for the severe cases of sulcus 23 Pérouse R, Coulombeau B. The so-called vocal cord striae: anatomoclinical
aspects (in French). Rev Laryngol Otol Rhinol 2005; 126:301–304.
striae major is a complex procedure that requires a skilled 24 Witzig E, Cornut G, Bouchayer M. Anatomoclinical study and treatment of the
surgeon and a team effort due to a long rehabilitation epidermoid cyst and vocal cord sulcus: review of 157 cases (in French). Lês
program. The treatment goal is to improve functionality cahiers d’ORL 1983; 47:765–778.
25 Remacle M, Lawson G, Watelet JB. Carbon dioxide laser microsurgery of
and to reach a stable voice, with reduced effort, which does benign vocal fold lesions: indications, techniques, and results in 251 patients.
not always correlate with a perfectly normal vocal fold. Ann Otol Rhinol Laryngol 1999; 108:156–164.
26 Sataloff RT, Spiegel JR, Hawkshaw MJ. Vocal fold scar. Ear Nose Throat J
1997; 76:776.
References and recommended reading 27 Hsiung M-W, Kang B-H, Pai L, et al. Combination of fascia transplantation and
Papers of particular interest, published within the annual period of review, have fat injection into the vocal fold for sulcus vocalis: long-term results. Ann Otol
been highlighted as: Rhinol Laryngol 2004; 113:359–366.
of special interest 28 Sataloff RT, Hawkshaw MJ, Divi V, Heman-Ackah YD. Voice surgery. Otolar-
of outstanding interest yngol Clin North Am 2007; 40:1151–1183; ix.
Additional references related to this topic can also be found in the Current A detailed and comprehensive article on voice surgery.
World Literature section in this issue (p. 578).
29 Tsunoda K, Kondou K, Kaga K, et al. Autologous transplantation of fascia into
1 Giacomini C. Report on the anatomy of the negro (in Italian). Acad Med Torino the vocal fold: long-term result of type-1 transplantation and the future.
1892; 40:17–61. Laryngoscope 2005; 115:1–10.
30 Zeitels SM, Mauri M, Dailey SH. Medialization laryngoplasty with Gore-Tex for
2 Arnold GE. Dysplastic dysphonia: minor anomalies of the vocal cords causing
voice restoration secondary to glottal incompetence: indications and obser-
persistent hoarseness. Laryngoscope 1958; 68:142–158.
vations. Ann Otol Rhinol Laryngol 2003; 112:180–184.
3 Luchsinger R, Arnold GE. Voice, speech, language, clinical communicology:
31 Isshiki N, Okamura H, Ishikawa T. Thyroplasty type I (lateral compression) for
its physiology, pathology. Belmont: Wadsworth Publishing; 1965.
dysphonia due to vocal cord paralysis or atrophy. Acta Otolaryngol 1975;
4 Hirano M. Phonosurgery: basic and clinical investigations. Otol Futuoka 80:465–473.
1975; 21:239–242. 32 Su C-Y, Tsai S-S, Chiu J-F, Cheng C-A. Medialization laryngoplasty with strap
5 Itoh T, Kawasaki H, Morikawa I, Hirano M. Vocal fold furrows. A 10-year review muscle transposition for vocal fold atrophy with or without sulcus vocalis.
of 240 patients. Auris Nasus Larynx 1983; 10 (Suppl):S17–S26. Laryngoscope 2004; 114:1106–1112.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
520 Laryngology and bronchoesophagology
33 Grellet M, Carneiro CG, Aguiar LN, et al. Pediculous graft technique for sulcus 38 Gasparini G, Behlau M, Hogikyan ND. Quality of life and voice: study of a
vocalis correction (in Portuguese). Rev Bras Otorrinolaringol 2002; 68:75– Brazilian population using the voice-related quality of life measure. Folia
79. Phoniatr Logop 2007; 59:286–296.
34 Pontes P, Behlau M. Treatment of sulcus vocalis: auditory perceptual and 39 Behlau M, Oliveira G, Santos LDMAD, Ricarte A. Validation in Brazil
acoustical analysis of the slicing mucosa surgical technique. J Voice 1993; of dysphonia impact self-assessment protocols (in Portuguese). Pró-Fono
7:365–376. Revista de Atualização Cientı́fica 2009; 21:326–332.
35 Gama A, Becker C, Pontes P. Treatment of iatrogenic vocal fold scar post-
40 Oliveira G, Behlau M, Santos I. Cross-cultural adaptation and validation of the
microsurgery for minor structural alteration (in Portuguese). O Melhor que
voice handicap index into Brazilian Portuguese. J Voice 2010 [Epub ahead of
Vi e Ouvi III, Atualização em Laringe e Voz. Rio de Janeiro: Revinter; 2001.
print].
pp. 117–124.
36 Macedo Filho E, Caldart A, Macedo C, et al. Inner section of the vocal 41 Epstein R, Hirani SP, Stygall J, Newman SP. How do individuals cope with
ligament: new technique for sulcus vocalis treatment (in Portuguese). Arq Int voice disorders? Introducing the Voice Disability Coping Questionnaire.
Otorrinolaringol 2007; 11:254–259. J Voice 2009; 23:209–217.
37 Welham NV, Dailey SH, Ford CN, Bless DM. Voice handicap evaluation of 42 Behlau M, Murry T. Voice therapy for benign vocal fold lesions and scars in
patients with pathologic sulcus vocalis. Ann Otol Rhinol Laryngol 2007; singers and actors. In: Benninger M, Murry T, editors. The performer’s voice.
116:411–417. San Diego: Plural; 2006. pp. 179–194.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.