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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 69-73

Injection laryngoplasty in the treatment of vocal cord sulcus vocalis

Department of Otolaryngology, King Abdulaziz University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission11-Jun-2020
Date of Decision19-Aug-2020
Date of Acceptance10-Sep-2020
Date of Web Publication06-Jan-2021

Correspondence Address:
Manal A Bukhari
Department of Otolaryngology, King Abdulaziz University Hospital, King Saud University, P.O Box: 245, Riyadh 11411
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_66_20

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Objective: The objective is to review all cases of sulcus vocalis that were treated surgically with injection laryngoplasty and study their demographic data, ways of presentation, endoscopic evaluation, modality of treatment, and voice outcome. Materials and Methods: This is a retrospective study of 60 patients with sulcus vocalis who were treated surgically at King Abdulaziz University Hospital, King Saud University. The collected data included information on gender, age, symptoms, time of onset, endoscopic examination, surgical management, and voice outcome. Results: A total of 60 patients were included in this study, of which 53.3% were male and 46.7% were female. The mean age was 27.4 (11.06 standard deviation). Childhood presentation was positive in 61.7% of the cases and 8.3% had family history. There was a significant improvement in postoperative glottal gap and voice handicap index (VHI) after injection laryngoscopy and there were many positive significant correlations. The first correlation was between the preoperative and postoperative glottal gap (Spearman rank correlation coefficient r = 0.368). The second was between preoperative VHI and postoperative glottal gap (Spearman rank correlation coefficient r = 0.595). The third was between preoperative and postoperative VHI (Spearman rank correlation coefficient r = 0.832). The follow-up period ranged from 6 months to 5 years. Conclusion: Injection laryngoplasty is a promising surgical modality of treatment for sulcus vocalis, which shows significant improvement in voice outcome postoperatively. The management is still challenging and there is still no unified method for treating such condition.

Keywords: Dysphonia, injection laryngoplasty, sulcus vocalis, vocal cord/fold, voice fatigue

How to cite this article:
Bukhari MA, Al-Amro MS, Al Harethy SE, Malki KH, Mesallam TA, Farahat M. Injection laryngoplasty in the treatment of vocal cord sulcus vocalis. J Nat Sci Med 2021;4:69-73

How to cite this URL:
Bukhari MA, Al-Amro MS, Al Harethy SE, Malki KH, Mesallam TA, Farahat M. Injection laryngoplasty in the treatment of vocal cord sulcus vocalis. J Nat Sci Med [serial online] 2021 [cited 2023 Feb 9];4:69-73. Available from: https://www.jnsmonline.org/text.asp?2021/4/1/69/306264

  Introduction Top

Sulcus vocalis refers to a longitudinal groove along the medial surface of the vocal folds. The groove is located in the superficial layer of the lamina propria (LP). In a great number of cases, it is adherent to the vocal ligament resulting in changes involving physical disruption of the vocal fold edge contour, distorted LP, extracellular matrix, and impaired glottal closure.[1]

The diagnosis, evaluation, and management of these lesions are a true challenge.

Patients present varying symptoms depending on the severity of the condition, which is judged by the size of the glottic gap. Hoarseness, voice fatigue, poor volume, breathy voice, choking, and aspiration are all reported in the literature.[2] Video-stroboscopy is a highly effective diagnostic tool for sulcus vocalis.[3] Etiology is still unclear, as it can be either congenital or acquired secondarily from phonotrauma, surgery, or infection. The treatment of sulcus vocalis is still a therapeutic challenge. The goal of all modalities of treatment is to improve the voice quality, but full recovery to the normal voice is almost never achieved. The results of voice therapy are not predictable and not encouraging. The goal of surgical intervention is to improve glottic efficiency through true vocal fold augmentation laryngoplasty and improve the vibratory pattern of vocal fold through manipulation of LP.[4],[5] Our aim in this study is to find a good modality in the treatment of sulcus vocalis that will give us promising results in improving voice quality. We reviewed all cases of sulcus vocalis that were treated by injection laryngoplasty and assess their voice outcome postoperatively.

  Materials and Methods Top

Ethical considerations

  • This retrospective study was approved by the Institutional Review Board of collage of medicine, King Saud University, Riyadh, Saudi Arabia
  • Approval from the ENT and medical records departments for the review of the records
  • All patients had signed an informed consent after explaining the details of the procedure, benefits, risks, and possible complications by the assigned consultant.

A review was conducted for medical records of the patients with an endoscopic and intraoperative diagnosis of sulcus vocalis that were treated with injection laryngoplasty at King Abdullaziz University Hospital in Riyadh, Saudi Arabia.

Sixty patients were enrolled according to the following inclusion criteria: Typical and clear videolaryngostroboscopic image of the lesion and diagnosis confirmation by direct laryngoscopy. Incomplete medical records or patients with doubtful diagnosis were excluded.

Laryngostroboscopy was performed using laryngostroboscopy station (Model 9200C, Kay Pantex, Montvale, NJ, USA).

Data collected from medical records included information on patient's name, age, gender, vocal symptoms, time since symptoms onset, history of previous laryngeal microsurgery, voice handicap index (VHI), videolaryngoscopic examination result, management plans, and postsurgery voice outcome. All surgeries were performed by a senior physician.

Wilcoxon test was used to compare the preoperative and postoperative results of gap size and VHI. Spearman rank correlation coefficient was used to measure correlation between the gap size and the VHI.

The statistical package for the social science version 20 (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses and the level of significance was set at P ≤ 0.05.

  Results Top

The diagnosis of the sulcus vocalis is based on the morphological shape and loss of propagation of mucosal wave over the sulcus lesion. A total of 60 patients who had a confirmed diagnosis of sulcus vocalis and who had been treated by injection laryngoplasty were assessed. Of these, 32 were male (53.3%) and 28 were female (46.7%). The mean age of the study group was 27.42 years (11.06 standard deviation [SD]).

Thirty-seven sulcus patients (61.7%) presented with dysphonia and voice fatigue, whereas 23 patients (38.3%) complained of dysphonia alone. Positive family history of change of voice was reported in five patients (8.3%). Around two-thirds of the patients (n = 37) had reported voice symptoms since childhood (61.7%). Seven cases only (11.7%) had previous laryngeal surgery.

Most of the patients had bilateral sulci (n = 54) (90%) while three patients (5%) had sulcus in the right side and three had sulcus in the left side (5%).

The subjective size of preoperative glottal gap during phonation is presented in [Table 1].
Table 1: Size of preoperative gap in mm

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The types of injectable materials used in true vocal fold injection augmentation are presented in [Table 2]. The most common materials used were autologous fat and restylane (33.3%).
Table 2: Types of materials injected

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Postoperative glottal gap during phonation is shown in [Table 3].
Table 3: Size of postoperative

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[Table 4] shows a comparison between preoperative and postoperative VHI and phonatory glottal gap.
Table 4: Comparison between preoperative and postoperative VHI and phonatory glottal gap

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Only 13 patients had preoperative and postoperative VHI reports, and the mean of preoperative VHI was 30.8 (3.64 SD).

The mean size of preoperative glottal gap during phonation was 2.15 mm (0.57 SD). 39 patients (65%) had a 2 mm phonatory glottal gap, whereas 6 patients (10%) presented with phonatory glottal gap of 1 mm.

The mean of postoperative VHI was 20.8 (5.03 SD), and 16 patients (26%) had no postoperative glottal gap during examination, while the mean size of postoperative glottal gap in the remaining group was 0.8 (0.54 SD) and two-thirds of the patients (66.7%) had a 1 mm postoperative glottal gap. Both parameters showed significant reduction in their postoperative value (P = 0.00), although the mean of postoperative VHI (20.8) did not reach the normal value.

There was a significantly higher number of patients with childhood presentation among the postoperative glottal gap group (P = 0.003), shown in [Table 5].
Table 5: Relation between childhood presentation and postoperative gap

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In this study group, there were many positive significant correlations. The first was between the preoperative and postoperative glottal gap (Spearman rank correlation coefficient r = 0.368). The second was between preoperative VHI and postoperative glottal gap (Spearman rank correlation coefficient r = 0.595). The third was between preoperative and postoperative VHI (Spearman rank correlation coefficient r = 0.832).

[Table 6] shows the follow-up period of cases which ranges from 6 months to more than 5 years (only in 2 cases [3.3%]). Most patients (41.7%) were followed up for 2 years.
Table 6: Follow-up period

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  Discussion Top

Sulcus vocalis is a challenging problem especially because of the different management options and unpredictable responses. Sulcus disorders of the vocal folds were divided into three groups according to clinical and histopathological features. In Type 1, the invagination is limited to the LP and does not cause vibratory defects thus is considered physiological. In Type 2, the invagination is along the vocal fold length and causes vibratory defects and dysphonia. It is called sulcus vergeture. Type 3, which is also called the pocket or pouch type, is considered the true sulcus vocalis and the epithelial invagination can reach up to the vocalis muscle layer and/or vocal ligament and cause serious dysphonia. Type 2 and 3 are considered as pathologic types. The depth of the sulcus determines the type and the severity of the symptoms.[1]

The etiology of sulcus vocalis is still controversial. Cakir et al.[6] found sulcus vocalis in monozygotic twin sisters. It is proposed that sulcus vocalis is a congenital condition that results from faulty development of the fourth and sixth branchial arches.[1]

Martins et al.[7] reported four cases of sulcus vocalis in close relatives, which indicates a probable genetic etiology. Malki[8] found a positive family history of voice problems in 9.5% of patients. Our study also shows that 8.5% of the patients reported family history of voice change. Early childhood presentation of voice change is another factor that supports the congenital cause of this disease. Our study shows that 61.7% of patients had early child presentation. There are many hypotheses supporting the acquired cause of sulcus vocalis; which can be divided into surgical, including over resection of the superficial layer of LP; and nonsurgical, including voice abuse, untreated benign lesions, and infections such as tuberculosis.[1],[2],[8]

Sulcus vocalis is one of the conditions that show male predominance. Sunter et al.[9] reported the incidence to be about 1.46 times in males than in females. In another clinical study, it was higher in males in subjects above than 50 years.[10] In our study, there was no difference between the two sexes.

In the literature, the incidence of sulcus vocalis varies between 0.4% and 48%, which is probably related to different types and the high chance of missing the physiological type. Hsiung et al.[11] found the incidence of this disease to be 36% and Sunter et al.[9] had close finding as it was 39%, while Malki[8] found that the prevalence of this disease was 3.8%.

Laryngoscopic examination is required for the diagnosis, which usually shows bowed spindle shaped vocal folds that do not approximate. In addition, medial furrows are seen during inhalation and supraventricular hyperfunction. Impaired vibration can be assessed with stroboscopic examination.

VHI is a subjective questionnaire of 30 questions. The original version was introduced by Jacobson et al.[12] and the aim is to know the functional, physical, and emotional impacts of the voice disorder on the patient's quality of life. VHI was translated to many languages and was also shortened to 10 questions to shorten the length of time required to complete it. Malki et al.[13] validated the Arabic version of the VHI, which was used in only 13 patients.

The treatment of sulcus vocalis is still a therapeutic challenge. Several techniques, such as speech therapy, phonosurgery, and molecular therapy, have been described as options to treat sulcus vocalis. Medical management is usually not an option except to treat conditions that may affect the surgical outcome, such as gastroesophageal reflux disease and allergic rhinitis, and control patient habits of smoking and drinking alcohol. Voice therapy plays an effective role, especially in patients with voice abuse, in improving phonatory technique and vocal hygiene. It is considered as an essential adjunctive measure. Malki[8] advised all the patients in his study to start with voice therapy. Only 70% of the study group participated in voice therapy and only 38.4% of them reported reasonable improvement in their voice after voice therapy. The patients who did not improve and did not agree to go for voice therapy were offered vocal fold augmentation under general anesthesia.

Surgical management of the sulcus vocalis is the real challenge, as there is still no definite way of management. It is still growing every day and it is a fertile field for researches.

Multiple surgical methods have been described in the management of sulcus vocalis, all of which aim to achieve satisfactory glottic closure leading to improved voice quality. Options available for each case are different from each other depending on the severity of the condition. Many modalities of treatment have been tried, each having its own advantages and disadvantages. These include injection laryngoplasty, medialization thyroplasties, incision with undermining, and direct excision with or without laser ablation.

Hsiung et al.[14] and Pinto et al.[15] used fascia with fat for vocal cords augmentation. Hsiung et al. used fascia lata while Pinto et al. used temporalis fascia. Both concluded that this was a good option, giving better results than fat injection alone. The procedure is considered simple with low cost and good results.

Remacle et al.[16] used the scanning CO2 laser surgery with collagen injection, which provides better vocal fold closure and vibration, improved vocal performance, and reduced vocal fatigue.

Kishimoto et al.[5] used atelocollagen sheet (terudermis) implant for the treatment of sulcus vocalis or scarred vocal folds, and they observed gradual improvement in most cases over 1 year after surgery, which suggests that the implant has restorative effects in these cases.

In our study, we used different injectable materials (some are not widely used for the same condition), including cymetra, autologous fat, radiesse, and restylane. Hydrodissection was done in some cases. All materials we used gave satisfactory subjective outcome as the voice quality improved as well as satisfactory objective outcome as observed in the improvement in the preoperative glottic gap compared to the postoperative gap and also in the preoperative VHI compared to the postoperative result. We observed that the smaller the preoperative gap the better the outcome and the patients with childhood symptoms are more likely to have persistent postoperative gap. Our study can open the way for more researches with larger number of patients and longer duration of follow-up.

  Conclusion Top

Sulcus vocalis management is the area of interest for most researchers. In our study, we found that injection laryngoplasty is a promising modality in the management of surgical cases of sulcus vocalis. The management is still challenging and there is still no unified method for treating such a condition. More studies are required to find the best management modality.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sreedevi N, Pebbili GK, Prakash TK, Bharadwaj SS. Electroglottographic patterns in physiologic and pathologic types of sulcus vocalis. J Laryngol Voice 2015;5:2-6.  Back to cited text no. 1
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Bohlender J. Diagnostic and therapeutic pitfalls in benign vocal fold diseases. GMS Curr Top Otorhinolaryngol Head Neck Surg 2013;12:Doc01.  Back to cited text no. 2
Akbulut S, Altintas H, Oguz H. Videolaryngostroboscopy versus microlaryngoscopy for the diagnosis of benign vocal cord lesions: A prospective clinical study. Eur Arch Otorhinolaryngol 2015;272:131.  Back to cited text no. 3
Hwang CS, Lee HJ, Ha JG, Cho CI, Kim NH, Hong HJ, et al. Use of pulsed dye laser in the treatment of sulcus vocalis. Otolaryngol Head Neck Surg 2013;148:804-9.  Back to cited text no. 4
Kishimoto Y, Hirano S, Kojima T, Kanemaru SI, Ito J. Implantation of an atelocollagen sheet for the treatment of vocal fold scarring and sulcus vocalis. Ann Otol Rhinol Laryngol 2009;613-20.  Back to cited text no. 5
Cakir ZA, Yigit O, Kocak I, Sunter AV, Dogan M. Sulcus vocalis in monozygotic twins. Auris Nasus Larynx 2010;37:255-7.  Back to cited text no. 6
Martins RH, Silva R, Ferreira DM, Dias NH. Sulcus vocalis: Probable genetic etiology. Report of four cases in close relatives. Braz J Otorhino Laryngol 2007;73:573.  Back to cited text no. 7
Malki KH. Prevalence of sulcus vocalis in patients visiting outpatient voice clinics at King Saud University. Saudi J Otorhinol Gol Head Neck Surg 2014;16:24-30.  Back to cited text no. 8
Sunter AV, Yigit O, Huq GE, Alkan Z, Kocak I, Buyuk Y. Histopathological characteristics of sulcus vocalis. Otolaryngol Head Neck Surg 2011;145:264-9.  Back to cited text no. 9
Rameshkumar E, Rosmi TK. Prevalence of age, gender and pathological conditions of vocal cords leading to hoarseness of voice in a tertiary care hospital. Int J Adv Med 2016;3:345-8.  Back to cited text no. 10
Hsiung MW, Woo P, Wang HW, Su WY. A clinical classification and histopathological study of sulcus vocalis. Eur Arch Otorhinolaryngol 2000;257:466-8.  Back to cited text no. 11
Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al. The voice handicap index (VHI): Development and validation. J Speech Lang Path 1997;6:66-70.  Back to cited text no. 12
Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T. Validation and cultural modification of Arabic voice handicap index. Eur Arch Otorhinolaryngol 2010;267:1743-51.  Back to cited text no. 13
Hsiung MW, Kang BH, Pai L, Su WF, Lin YH. Combination of fascia transplantation and fat injection into the vocal fold for sulcus vocalis: Long-term results. Ann Otol Rhinol Laryngol 2004;113:359-66.  Back to cited text no. 14
Pinto JA, Silva Freitas ML, Carpes AF, Zimath P, Marquis V, Godoy L. Autologous graft for treatment of vocal sulcus and atrophy. Otolaryngol Head Neck Surg 2007;137:785-91.  Back to cited text no. 15
Remacle M, Matar N, AmoussaK, Jamart J, Lawson G. CO2 laser surgery for sulcus vocalis and related lesions. Otolaryngol Head Neck Surg 2010;143:78-9.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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