Bilateral sulcus vocalis.

A22-year-old law student presented with "laryngitis." His hoarseness had recently diminished, but it had not resolved. He complained of difficult phonation and fatigue, and he said that his speaking voice was higher than usual. His history included two episodes of upper respiratory infection (URI): one 2 years earlier and the other 4 years earlier. During the more recent URI, he had been aphonic for 1 day.

Flexible and rigid endoscopy demonstrated right vocal fold hypomobility; this finding was confirmed by electromyography, which revealed a 30% reduction in recruitment in both the superior and recurrent laryngeal nerves on the right. Glottic insufficiency and a spindle-shaped larynx were also noted. Stroboscopy demonstrated bilateral sulcus vocalis, which was worse on the left; this was confirmed during microdirect laryngoscopy (figure).

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The sulcus vocalis was corrected with bilateral fat implantation followed by bilateral type 1 thyroplasty. Lipoinjections were later administered to achieve further medialization and to add bulk to the vocal fold.

Ford et al (1) categorized sulcus disorders into three types:

* Type 1 is a physiologic variant characterized by atrophy. The lamina propria is intact. It is present in approximately 10% of people. It causes no subjective phonatory abnormality, and the mucosal wave is not limited.

* Type 2 sulcus (sulcus vergeture) is a deficiency in the superficial lamina propria (SLP) in which a thin layer of SLP lies between the epithelium and the vocal ligament. The voice is disturbed by this deficiency, and wave propagation is slightly limited. Conservative therapy is frequently unsuccessful, but surgery is fairly effective. The senior author (R.T.S.) finds that sulcus vergeture is more common and less disruptive to the voice than Ford et al suggested. Voice therapy will frequently allow a patient to work around the problem. We consider type 1 and type 2 sulcus to be in the same category.

* Type 3 is sulcus vocalis. The SLP is completely absent and, as a result, the epithelium adheres to the vocal ligament. Sulcus vocalis is seen on stroboscopy as a linear segment of the vocal fold where the wave does not propagate. The voice is usually hoarse. This condition can be corrected surgically. Sulcus lesions are both congenital and acquired (e.g, a result of vocal fold trauma).

Reference

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

Robert Eller, MD; Mary Hawkshaw, BSN, RN, CORLN; Robert T. Sataloff, MD, DMA

From the American Institute for Voice and Ear Research (Dr. Eller and Ms. Hawkshaw) and the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine and Graduate Hospital (Dr. Sataloff), Philadelphia.