Dr. T. Balasubramanian M.S.
Synonyms: Vocal fold
cleft, vocal fold scarring.
Definition: Sulcus vocalis
is caused by migration of the vocal fold epithelium in to the
normally convex lamina propria, causing a cleft in the vocal
fold. The presence of this cleft alters the way vocal folds
osscilate causing voice changes.
Classification of sulcus
vocalis: Ford etal classified sulcus vocalis into three types:
In all these types the cleft is present on the medial surface of the
Ford Type I: Here the longitudinal depression of the
vocal fold epithelium extends into the lamina propria, but does not
reach the vocal ligament. This depression extends often along
the full length of the vocal cord. This sulcus is commonly
present and cause only a mild vocal dysfunction. Hence it is
often termed as physiologic sulcus.
Ford Type II:
The sulcus extends throughout the full length of the vocal
cord. The depression extends upto the vocal ligament, there is
also an associated loss of lamina propria. This anamoly causes
a disruption of the mucosal wave pattern which is responsible for
normal voice production.
Ford Type III: Here the sulcus is
deep and focal in nature giving the apprearance of a pit. The
whole length of the cord is not involved. There is also an
associated loss of lamina propria. This type of defect causes
a disruption of the mucosal wave. Histology of these lesions
show diffuse fibrosis, neovascularisation and
showing the various types of sulcus vocalis
Fig showing the various types of sulcus
Etiopathogenesis of sulcus vocalis
(Theories): As usual congenital and acquired theories have
been postulated to explain the etiopathogenesis of sulcus
Arnold Bouchayer theory: This theory
attributes a congenital cause to explain the etiopathogenesis
of sulcus vocalis. This theory postulates a faulty
genesis of the 4th and 6th branchial arches as the cause for
sulcus vocalis. Epidermoid cysts present in the vocal fold due
to this faulty genesis of 4th and 6th arches are believed to rupture
causing this disorder. Genetically, in these
patinets vocal fold scars are characterised by replacement of
the normal micro architecture by disorganised collagen causing a
reduction in the volume of vocal fold thus making it less pliable to
vibrations during speech.
The following factors favour this
1. Appearance in childhood.
2. Not known
to recur after surgery.
Microscopically these lesions are characterised
by the presence of:
theory: attributes this condition to be acquired in
nature. Trauma and mycobaterial infections have been
implicated as probable causes for this condition. In fact a
significant amount of sulcus vocalis has been found in the
opposite vocal cord when the ipsilateral vocal cord is affected
by malignant lesion. This lends credence to this theory.
Recent authors have accepted both these theories as probable
cause of sulcus vocalis.
features: Patients will complain of chronic hoarseness of voice,
vocal insufficiency and loss of quality of voice.
Indirect laryngoscopy and direct laryngoscopic examinations will
demonstrate the presence of sulcus vocalis in the free margin of the
vocal folds. On video stroboscopy loss of mucosal wave in the
affected portions of the vocal folds will be clearly
Management: The goal in managing
this problem is to improve the glottic efficiency, reduce strain to
the vocal folds, and improvement in the overall voice
1. Patient must be advised adequate voice
2. Speech therapy and speech councelling should be
3. GERD if present must be aggressively
4. Rhinosinusitis if present must be
Fig showing sulcus
techniques have been formulated for treatment of sulcus
vocalis. Before prceeding with surgical management one aspect
should be clearly assessed: the ability of the surgeon to
visualise the full length of the vocal cord
endoscopically. If such clear visualisation is not
possible then medialisation thyroplasty or injection thyroplasty or
voice therapy may be resorted to.
showing the decision process in surgical management of sulcus
This technique is used
to close the glottic gaps commonly seen in sulcus vocalis.
This procedure cannot be performed endoscopically. This is an
external procedure which uses different medialising implants like
silastic, Gore-tex or hydroxyapatite blocks. Sometimes strap
muscles can also be used is autogenous graft is preferred.
Goretex is the preferred material to medialise the vocal fold.
This material not only reduces the glottic gap it also maintains the
normal pliability of the vocal folds. The surgical procedure
will be detailed elsewhere.
can be injected into the vocal fold thereby causing medialisation of
the injected vocal fold. This procedure can be preformed
through an endoscopic approach. This injection can be
performed under out patient settings. This injection closes
the glottic gap causing an improvement in the quality of
voice. The only problem with this method is that collagen has
been known to be absorbed by tissues. No long term study is
available to study the long term effects of this injection.
Large gaps cannot be treated by this method.
Cold redrape: This
procedure is performed under microlaryngeal approach. It
involves a longitudinal epithelial cordotomy with release of the
sulcus from its depth followed by simple redraping of the
epithelium. The major advantage of this procedure is that
implants need not be used and is a fairly simple procedure to
perform. The release of the tethered tissue helps to close the
glottic chink somewhat better. One major word of caution is
that the healing process of the epithelial cover is not under our
control, ultimately the operated area may heal with fibrosis
reducing the pliability of the vocal fold whereby worsening the
condition. Surgery must hence be performed with utmost caution
with minimal trauma to the covering mucosa.
with redraping: CO2 laser is used lto perform the
cordotomy. It has the advantage of excellent hemostasis with
minimal trauma to the surrounding tissues. Steroids are
injected at the time of redraping and fibrin glue is applied to the
epithelium to facilitate reapproximation and tissue healing of the
Slicing technique of Pontes and Behlau:
This technique utilises the principles of scar contracture
repair. The scar bands are interrupted with medial advancem
ent of vocal fold cover. In this procedure cuts of
varying lengths are made in the coronal plane of the vocal fold to
release the longitudinal scar band. This procedure is reserved
for cases of severe deformities where less aggressive surgical
management may not suffice.
Fat injection: Glottic insufficiencies can be corrected by
injecting fat into the paraglottic space. This can be
achieved via a laryngofissure
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