Vocal fold scar/sulcus vocalis.

A 49-year-old man, a professional voice user, presented with complaints of vocal fatigue, instability after prolonged voice use, and a decrease in the range and fullness of his voice. He could not recall any sudden voice loss or prolonged hoarseness in the past. Physical examination, including flexible and rigid videostroboscopy, revealed supraglottic hyperfunction, bilateral vocal fold hypomobility, and signs of laryngopharyngeal reflux (LPR) disease. Laryngeal electromyography showed a 20 to 30% decreased recruitment in the distribution of the right superior laryngeal nerve.

The LPR was treated aggressively with lifestyle modifications, twice-daily proton-pump inhibitor therapy, and an [H.sub.2] blocker at bedtime. Speech therapy corrected the hyperfunction, further unmasking symptoms of the subtle paresis of the right vocal fold. A right-sided Gore-Tex thyroplasty resulted in a substantial improvement of the voice on the operating table and sustained improvement during the postoperative period. However, 2 months following surgery, after the patient's stamina and fullness had returned, he still experienced periods during which his voice would break after heavy use. Strobovideolaryngoscopy detected the presence of a small sulcus vocalis (figure).

A sulcus vocalis classically manifests as a linear grooving of the medial face of the vocal fold. However, the lesion in our patient represented an area of scar with a loss of the superficial lamina propria in a discrete area, leading to the adherence of the epithelium to the vocal ligament. There was a loss of transparency and bulk of the vocal fold edge in that area. The presence of vascular ectasias (punctuate vessels surrounding the sulcus) suggested a remote traumatic etiology. Under stroboscopic light, the area was seen to move as a mass without the normal vertical sheafing of the cover over the vocal fold body. Because the mucosal wave did not propagate through this area, it was reported as a focally adynamic segment. This lesion was seen consistently, although only briefly, within each vocal cycle.

Continued LPR therapy, voice therapy to help the patient work around his problem, and vocal hygiene were recommended. Procedural interventions--ranging from steroid injection, to a scar release, to autologous fat implantation--are appropriate when conservative measures fail to relieve symptoms. Current research on hyaluronic acid, growth factors, biomaterials, and genetic reengineering may lead to improved therapy in the future.