Sulcus vocalis: a review

Artificial intelligence based diagnosis of sulcus: assesment of videostroboscopy via deep learning

PURPOSE

To develop a convolutional neural network (CNN)-based model for classifying videostroboscopic images of patients with sulcus, benign vocal fold (VF) lesions, and healthy VFs to improve clinicians' accuracy in diagnosis during videostroboscopies when evaluating sulcus.

MATERIALS AND METHODS

Videostroboscopies of 433 individuals who were diagnosed with sulcus (91), who were diagnosed with benign VF diseases (i.e., polyp, nodule, papilloma, cyst, or pseudocyst [311]), or who were healthy (33) were analyzed. After extracting 91,159 frames from videostroboscopies, a CNN-based model was created and tested. The healthy and sulcus groups underwent binary classification. In the second phase of the study, benign VF lesions were added to the training set, and multiclassification was executed across all groups. The proposed CNN-based model results were compared with five laryngology experts' assessments.

RESULTS

In the binary classification phase, the CNN-based model achieved 98% accuracy, 98% recall, 97% precision, and a 97% F1 score for classifying sulcus and healthy VFs. During the multiclassification phase, when evaluated on a subset of frames encompassing all included groups, the CNN-based model demonstrated greater accuracy when compared with that of the five laryngologists (%76 versus 72%, 68%, 72%, 63%, and 72%).

CONCLUSION

The utilization of a CNN-based model serves as a significant aid in the diagnosis of sulcus, a VF disease that presents notable challenges in the diagnostic process. Further research could be undertaken to assess the practicality of implementing this approach in real-time application in clinical practice.

Indigo Carmine Chromoendoscopy for the Diagnosis of Minor Structural Alterations of the Vocal Fold Cover. A New Application for the Technique

INTRODUCTION

Minor structural alterations (MSA) of the laryngeal mucosa are entities involving epithelial vocal cord covering modifications. Among differentiated structural alterations of the vocal cords are sulcus vocalis, epidermoid cysts, micro diaphragms, mucosal bridges, and vasculodysgenesis. While many of these MSA are evident and can be easily visible using conventional endoscopic methods, diagnosis can be difficult even with the help of stroboscopy. MSA can often go unnoticed and may be associated with polyps, cysts or vascular alterations. Its impact on the voice could be significant. In many cases, direct suspension laryngoscopy under general anesthesia is necessary to obtain a definitive diagnosis.

OBJECTIVES

The purpose of this article is to describe a new diagnostic endoscopic method that uses contrast dyes, such as indigo carmine, for the detection of MSA of the vocal fold mucosal covering.

MATERIAL AND METHODS

This research work uses the contrast dye Indigo Carmine as an endoscopic tissue stain, which is applied to the mucosal surface of the vocal cords under local anesthesia in the office or under general anesthesia in the operating room. The dye fills the interstices, highlighting irregularities such as depressions and elevations in architecture.

RESULTS

Our study involved performing indigo carmine chromoendoscopy procedures on patients suspected of having vocal fold MSA-type sulcus vocalis, mucosal bridge, or bag-type sulcus. We identified cases where this technique is useful for diagnosing previously undetected alterations, shedding light on dysphonia "without an apparent cause."

CONCLUSIONS

Indigo carmine chromoendoscopy is a useful technique for detecting MSA of the mucosal surface of the vocal folds. It has the potential to diagnose MSA in patients where current in-office endoscopic techniques are insufficient.

Predictive Factors Affecting the Outcomes Of angiolytic Laser-Assisted Glottoplasty for Sulcus Vocalis

OBJECTIVE

Glottoplasty using an angiolytic laser is an option for the surgical treatment of sulcus vocalis. In this study, we sought to evaluate the clinical outcomes of using a 532-nm diode laser in sulcus vocalis patients and to identify predictive factors of improved voice outcomes after angiolytic laser-assisted glottoplasty.

METHODS

A total of 66 patients with sulcus vocalis who underwent laser-assisted glottoplasty with a 532-nm diode laser were included in this study.

RESULTS

3 months after surgery, GRBAS scores, patient-reported outcome measures, fundamental frequency (F0), jitter percent, and noise-to-harmonic ratio decreased significantly, while cepstral peak prominence (CPP) of vowel and sentence production increased. Patients with auditory-perceptual improvements showed greater improvement in the Voice Handicap Index (VHI) scores, F0, and CPP of vowel and sentence production compared to those with no improvement. While young male patients with preoperatively high F0 were predicted to have favorable outcomes, the type of sulcus vocalis was not predictive of treatment outcomes. Patients treated with lower laser power showed better improvement in the VHI scores postoperatively than those who received higher laser power per vocal fold. Combined injection laryngoplasty with laser glottoplasty was effective in lowering the F0, especially in male patients with high F0.

CONCLUSION

A 532-nm diode laser is useful for treating sulcus vocalis. Young male patients and individuals with preoperatively high F0 showed better voice outcomes after laser glottoplasty. Laser power and combined injection laryngoplasty are considered to affect improvement in the VHI and lowering F0 after laser glottoplasty in sulcus vocalis.

Evaluating Interventions for Sulcus Vocalis or Vocal Fold Scar: A Systematic Review and Meta-analysis

BACKGROUND

Sulcus vocalis reflects varying degrees of vocal cord lamina propria (LP) damage. Many interventions have been discussed in the literature for addressing sulcus vocalis, but there is no universally accepted gold standard for its management.

AIM

We aim in our study to collectively evaluate the effectiveness of different relevant interventions in the literature used for sulcus vocalis or vocal fold scar.

METHODS

We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled in our single-arm meta-analysis as mean change (MC) and with 95% confidence interval (CI).

RESULTS

Our systematic review and meta-analysis included 43 studies encompassing 1302 patients. The jitter parameter indicated that laser degeneration and LP regeneration/scar degradation led to the highest improvements compared to their baseline, with pooled MC of -0.897 and -0.893, respectively. Graft interposition showed a MC of -0.848, while medialization and dissection had less pronounced changes at -0.200. Shimmer parameter results were similar, with medialization and laser degeneration leading to MC of -2.129 and -2.123, while LP regeneration/scar degradation and graft interposition showed smaller changes MC -1.530 and -1.217. For the noise-to-harmonic ratio (NHR) parameter, LP regeneration/scar degradation demonstrated MC = -0.028. In aerodynamics outcomes, graft interposition and LP regeneration/scar degradation showed the highest MCs in mean phonatory time (MPT) (4.214 and 3.467, respectively). Endoscopic outcomes for mucosal wave showed high improvements in medialization and graft interposition (MC = 10.40 and 10.18, respectively). Perceptual outcomes favored graft interposition in various parameters, while laser degeneration performed well in most categories. Graft interposition and LP regeneration/scar degradation had a high voice handicap index (VHI) (MC = -27.195 and -19.269, respectively).

CONCLUSION

Laser degeneration and LP regeneration/scar degradation were particularly effective in improving acoustic parameters. In aerodynamics, graft interposition and LP regeneration/scar degradation improved vocal efficiency compared to their baselines. Medialization and laser degeneration had the largest impact compared to their baseline on shimmer and MPT. Endoscopic assessments showed that medialization and graft interposition had high improvement in mucosal waves, and perceptual outcomes were generally high with graft interposition and laser degeneration.

Laryngeal Applications of Platelet Rich Plasma and Platelet Poor Plasma: A Systematic Review

BACKGROUND

Platelet rich plasma (PRP) and platelet poor plasma (PPP) are regenerative therapies that offer the potential for improving care for disorders of the larynx. The laryngeal applications of these substances have been examined in both animals and humans. The goal of this systematic review is to examine the various applications of PRP and PPP in laryngology, assess the protocols for preparation and application of these substances and evaluate the outcomes and complications in both humans and animals.

METHODS

A search of PUBMED was conducted in April 2021 using combinations of keywords of "platelet rich plasma" and "platelet poor plasma" with keywords such as "larynx," "vocal folds," "laryngology," and others. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines were followed. Articles were reviewed by two independent coauthors and included based on selection criteria pertinent to the goals of this study. The risk of bias in the included studies was assessed by two independent co-authors using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Randomized Controlled Trials and JBI Critical Appraisal Checklist for Quasi-Experimental Studies. Data regarding the pathologies treated using PRP and PPP, PRP, and PPP preparation protocols, application protocols, human voice outcomes, histopathological animal outcomes, and complications were extracted from each of the studies and presented in tables.

RESULTS

Seven studies were included based on the selection criteria. PRP or PPP were used for vocal fold scar, sulcus, atrophy and palsy; acute vocal fold injury; glottic insufficiency, and graft healing. PRP or PPP were derived from autologous blood in a one- or two-step centrifugation process and administered via injection, soaking of cartilage grafts or topical application. Mean and median voice handicap index-10 (VHI-10) and voice handicap index (VHI) scores decreased following PRP or PPP injections in two human studies and one human study showed a similar VHI-10 score before and after PRP treatment. Videostroboscopy showed the absence of injection site reactions and at least temporary improvement in glottic gap or vibratory function following treatment in some patients. Other objective measures of voice outcomes in human studies showed improved phonatory function in the one-to-four-month period following PRP or PPP injections, with some patients experiencing a subjective decrease or return to baseline in phonatory function following the initial improvement period. Animal studies found elevated levels of growth factors, organized collagen deposition, decreased granulation tissue, increased vascularization, and increased cartilage proliferation in PRP treated laryngeal tissue.

DISCUSSION

PRP and PPP might have the potential to be safely used in the larynx and at least temporarily influence wound healing and vocal function. Further study using comparable outcome measurement tools is required to assess their role and efficacy in treating acute vocal fold injury, chronic vocal fold pathologies, graft healing, and other laryngeal applications.

Sulcus Vocalis: Clinical and Surgical Aspects

OBJECTIVES

To analyze clinical, vocal, and videolaryngoscopic parameters, as well as the treatments of patients with sulcus vocalis.

METHODS

This is an observational study. The medical records of patients diagnosed with sulcus vocalis (type II or III) were selected and demographic data, vocal symptoms, videolaryngostroboscopies, vocal analyses (perceptual and acoustic), and maximum phonation time (MPT) were collected. The vocal parameters of patients who underwent microsurgery to treat the sulcus were compared before and after surgery.

RESULTS

Exactly 109 patients were diagnosed with sulcus; however, only 60 completed the inclusion criteria (39 women and 21 men), with a mean age of 45 years. Hoarseness and vocal fatigue were reported in 100% and 88% of cases, respectively. Laryngoscopy indicated a type II sulcus (90%), type III sulcus (10%), and an association of the sulcus with other benign lesions (23%), especially polyps. Perceptual evaluations indicated mild to moderate dysphonia, roughness and breathiness of the voice, mean MPT of 10 seconds, and high values of jitter, pitch perturbation coefficient, and soft phonation index (SPI). Twenty-two patients (14 women and 8 men) underwent sulcus microsurgery. The surgery promoted a decrease in the GRBAS scores, an increase in the MPT, and a decrease in the SPI; however, other acoustic parameters remained unchanged.

CONCLUSIONS

Patients with sulcus vocalis had mild to moderate dysphonia, in addition to voice roughness and breathiness and elevated fundamental frequency. Surgical treatment improved vocal parameters but maintained some degree of dysphonia, indicating incomplete restoration of vocal qualities.

Assessment of Subjective and Objective Voice Analysis According to Types of Sulcus Vocalis

INTRODUCTION

Sulcus vocalis (SV) subtypes are difficult to diagnose. Non-invasive techniques are sometimes not feasible in the diagnosis. The study aims to demonstrate the effectiveness and applicability of objective and subjective voice analysis combined with videolaryngostroboscopic examination (VLS) in the diagnosis of SV types.

MATERIAL AND METHODS

This is a retrospective study that includes patients who presented to Phoniatric outpatient clinic with complaints related to voice and diagnosed with SV on VLS examination between 2017-2020. The SV type was determined based on VLS findings and the patients were categorized into respective groups. Between- and within-group assessment of objective and subjective voice analysis of SV types was conducted.

RESULTS

47 patients were included in the study; Type I, Type II, Type III SV patients were 16, 17, and 14 in number, respectively. Fundamental frequency (F0) and Shimmer (%) values were significantly high in Type II and III SV cases, whereas the Maximum Phonation Time (MPT) was significantly low. GRBAS, Voice Handicap Index -10 (VHI-10), Reflux Symptom Index (RSI) scores were statistically significantly high in pathological SV and Voice Related Quality of Life (V-RQOL) scores were low. A moderate correlation between VHI-10 and V-RQOL and between RSI and V-RQOL was detected.

CONCLUSIONS

Objective and subjective voice analysis in Type II and III SV show a significant difference compared to Type I SV. The use of objective and subjective voice analysis combined with VLS examination can be helpful in the diagnosis of SV types.

Options for treatment of a small glottic gap

Background

Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds.

Methods

This manuscript reviews the current literature regarding the options for treatment of glottic gap.

Discussion

This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap.

Level of Evidence

3a-Systematic review of case-control studies.

The Comparison of Narrow Band Imaging, White Light Laryngoscopy and Videolaryngostroboscopy in the Evaluation of Benign Vocal Fold Lesions

BACKGROUND

The aim of the study was comparing the diagnostic role of the white light (WL) endoscopy, video laryngostroboscopy (VLS), and narrow-band imaging (NBI) in the evaluation of the benign vocal fold lesions.

MATERIAL AND METHODS

From March 2018 to June 2019, a total of 118 cases were enrolled in this study. Ninety-eight patients were suspected with vocal fold nodules, cysts, polyps, and sulcus vocalis and 20 patients without a history of dysphonia. Each patient was examined by WL, VLS, and NBI endoscopy. Recorded images and videos were analyzed and scored by three otorhinolaryngologists who had at least 3 years of experience in phoniatrics field. The evaluation results were compared between the methods and the physicians.

RESULTS

A total of 118 cases were grouped by their confirmed diagnosis, vocal fold nodules (n = 28), vocal fold cyst (n = 24), vocal fold polyp (n = 9), and sulcus vocalis (n = 37). When the correct diagnosis rates of the physicians were compared, the statistical significance was found between the physicians in the WL and VLS method (P= 0.014, P= 0.027). No statistically significant difference was found among physicians in NBI method (P = 0.368). The difference between the diagnostic methods was found to be statistically significant in reaching the accurate diagnosis for benign vocal fold lesions (P< 0.001). While the difference between NBI-WL and VLS-WL was statistically significant (P< 0.001 and P< 0.001). The difference between NBI-VLS was not statistically significant while evaluating the vocal fold nodules, cysts, and sulcus vocalis separately (P= 0.102, P = 0.026, P = 0.157). Otherwise, it was statistically significant (P= 0.002) while evaluating total benign lesions in the study. The difference between NBI-VLS combination and VLS, NBI-VLS combination and VLS-WL combination were statistically significant (P< 0.001 and P= 0.001).

CONCLUSION

This study showed that NBI assessments have similar accuracy and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to VLS and have a higher value than WL endoscopy in reaching the diagnosis for benign vocal fold lesions. Therefore, NBI can be accepted as a promising approach to identify benign laryngeal lesions due to its optical properties.

Using Diffusion Tensor Imaging to Explore the Changes in the Microstructure of Canine Vocal Fold Scar Tissue

OBJECTIVE

To apply diffusion tensor imaging (DTI) in measurement of the diffusion characteristics of water molecules in vocal fold scar tissue, combined with the analysis of textural characteristics of collagen fibers in the cover layer of the vocal folds to explore the feasibility of DTI in the qualitative and quantitative diagnosis of vocal fold scars and the evaluation of microstructural changes of vocal fold scar tissue.

METHODS

A unilateral injury was created using micro-cup forceps in the left vocal fold of six beagles. The contralateral normal vocal fold was used as a self-control. Five months postinjury, the larynges were excised and placed into a magnetic resonance imaging (MRI) system (9.4T BioSpec MRI, Bruker, German) for scanning and extraction of the diffusion parameters, fractional anisotropy (FA) and tensor trace in the anterior, middle, and posterior portions of the vocal fold cover layer. These parameters were then analyzed for statistical significance between the scarred vocal fold and the normal vocal fold. After MRI scanning, the tissue of the vocal folds was divided into anterior, middle, and posterior parts for sectioning and staining with hematoxylin and eosin, and samples were subsequently digitally scanned for texture analysis. The irregularity parameters, energy, contrast, correlation, and homogeneity, of collagen fibers of the vocal folds and the mean gray value of collagen fibers were calculated by the gray-level co-occurrence matrix (GLCM) texture analysis method. The differences in the mean value of the two sides of the vocal fold were compared. In addition, Pearson correlation analysis was performed between DTI parameters and irregularity parameters.

RESULTS

The FA of the left vocal fold cover layer was significantly lower compared to the self-control group (P = 0.0366), and the tensor trace value on the left vocal fold cover layer was significantly higher compared to the self-control group (P = 0.0353). The FA was significantly higher in the anterior part of the right vocal fold cover layer compared to the middle and posterior parts of the same side (P = 0.0352), and the tensor trace was significantly lower in the anterior part of the right vocal fold cover layer compared to the middle and posterior parts of the same side (P = 0.0298). There were no significant differences in FA and tensor trace between the middle and posterior parts of the vocal fold cover layer. The mean gray value of the left vocal folds cover layer was significantly smaller than the right vocal fold cover layer (P = 0.0219), the energy of the left vocal fold cover layer was significantly smaller than that of the right vocal fold cover layer (P < 0.0001), the contrast of the left vocal folds cover layer was significantly larger than that of the right vocal fold cover layer (P = 0.0002), the correlation of the left vocal folds cover layer was significantly smaller than the right vocal fold cover layer (P = 0.0002), and the homogeneity of the left vocal folds cover layer was significantly smaller than the right vocal fold cover layer (P = 0.0003). Pearson correlation analysis yielded values of r = 0.926, P = 0.000 between the FA and mean gray value; r = -0.918, P = 0.000 between FA and energy; r = -0.924, P = 0.000 between the FA and homogeneity, r = -0.949, P = 0.000 between tensor trace and mean gray value; r = 0.893, P = 0.000 between the tensor trace and energy; and r = 0.929, P = 0.000 between the tensor trace and homogeneity.

CONCLUSION

FA and tensor trace can be used as effective parameters to reflect microstructural changes in vocal fold scars. DTI is an objective and quantitative method of analyzing vocal fold scarring, and it noninvasively evaluates the microstructure of vocal fold collagen fibers.

Development of an Animal Model for Type II Sulcus (Sulcus Vergeture)

OBJECTIVES

To develop a reproducible experimental animal model for sulcus vergeture in rabbits.

STUDY DESIGN

Experimental animal study.

MATERIAL METHOD

We evaluated three methods of inducing sulcus in twelve New Zealand white rabbits to produce a sulcus model. Experimental groups comprised: group 1 (n = 4) underwent submucosal injury following endolaryngeal epithelial incision; group 2 (n = 4) received submucosal injury via thyrotomy; group 3 (n = 4) received submucosal injury via thyrotomy, followed with horizontal mucosal lateralization suture. Right vocal folds of the rabbits underwent surgery to produce sulcus vocalis and left vocal folds were used for the comparison. In the sixth week after the procedure, the rabbits were sacrificed and the larynxes were harvested and analyzed histopathologically.

RESULTS

No animals in group 1 or 2 developed sulcus vocalis. Sulcus formation was observed in all rabbits in group 3, under endoscopic examination and microscopic sulcus formation was demonstrated for the first, second, and third rabbits. An epithelial depression area was seen at the glandular ductal opening zone for the fourth rabbit, but it could also be accepted as a sulcus formation.

CONCLUSION

We successfully developed a reproducible survival model for sulcus using a submucosal injury via thyrotomy, followed with a horizontal mucosal lateralization suture. This model provides the groundwork for future research into the applicability of new approaches for sulcus management.

Mechanisms of sound production in deer mice (Peromyscus)

Rodent diversification is associated with a large diversity of species-specific social vocalizations generated by two distinct laryngeal sound production mechanisms- whistling and airflow-induced vocal fold vibration. Understanding the relative importance of each modality to context-dependent acoustic interactions requires comparative analyses among closely related species. In this study, we used light gas experiments, acoustic analyses, and laryngeal morphometrics to identify the distribution of the two mechanisms among six species of deer mice (Peromyscus). We found that high frequency vocalizations (simple and complex sweeps) produced in close-distance contexts were generated by a whistle mechanism. In contrast, lower frequency sustained vocalizations (SVs) used in longer distance communication were produced by airflow-induced vocal fold vibrations. Pup isolation calls, which resemble adult SVs, were also produced by airflow-induced vocal fold vibrations. Nonlinear phenomena (NLP) were common in adult SVs and pup isolation calls, suggesting irregular vocal fold vibration characteristics. Both vocal production mechanisms were facilitated by a characteristic laryngeal morphology, including a two-layered vocal fold lamina propria, small vocal membrane-like extensions on the free edge of the vocal fold, and a singular ventral laryngeal air pocket known as the ventral pouch. The size and composition of vocal folds (rather than total laryngeal size) appears to contribute to species-specific acoustic properties. Our findings suggest that dual modes of sound production are more widespread among rodents than previously appreciated. Additionally, the common occurrence of NLP highlight the nonlinearity of the vocal apparatus, whereby small changes in anatomy or physiological control trigger large changes in behavioral output. Finally, consistency in mechanisms of sound production used by neonates and adults underscores the importance of considering vocal ontogeny in the diversification of species-specific acoustic signals.

Autologous Fat Plus Platelet-Rich Plasma versus Autologous Fat Alone on Sulcus Vocalis

Sulcus vocalis is a frequent cause of glottic insufficiency that leads to incomplete vocal fold closure during phonation. Type II sulcus vocalis is defined as a partial defect of the lamina propria (LP). Treatment with fillers, such as fat or hyaluronic acid (HA), in the vocal folds is widely used, but the duration of effect is variable. Platelet-rich plasma (PRP) can enhance the survival of autologous fat in fat grafting, and also is used to treat sulcus vocalis. This study aimed to compare the effectiveness of autologous fat graft versus fat graft plus PRP to treat type II sulcus vocalis. Thirty-four patients with a voice handicap index (VHI) ≥ 11 were randomized to two groups, which received LP injections of fat graft (n = 17) or fat graft plus PRP (n = 17). At 1 month and 6 months after injection, the VHI decreased significantly in both groups. The fat plus PRP group had better Jitter, Shimmer, and noise to harmonic ratio (NHR) in 1 month and 6 months after surgery. The fat plus PRP group resulted in lower VHI scores one month after surgery, and stroboscopy revealed sustained smaller gaps after six months. These results indicate that a combination of fat graft plus PRP is safe and effective for treating sulcus vocalis type II and associated vocal atrophy.

Vocal fold sulci - what are the current options for and outcomes of treatment?

PURPOSE OF REVIEW

Sulcus vocalis is a benign condition of the vocal folds that, according to its severity, can affect the quality of the voice of those who have it. Voice symptoms can range from mild to severe, affecting the quality of life of patients with this condition. Although different surgical and no surgical options have been described, no gold standard treatment has been described.

RECENT FINDINGS

New evidence supports congenital, inflammatory, and acquired theories for sulcus vocalis. Also, recent literature demonstrated the role of the epithelium in the pathogenesis, which makes the absence of superficial lamina propria no longer the only accepted hypothesis. Technological developments improved the in-office diagnostics capabilities for this condition, but vocal fold palpation remains the gold standard. Different benign laryngeal conditions are associated with sulcus vocalis and knowing when to treat those is very important. Different treatment options are available for sulcus vocalis, however, results are diverse and no strong recommendations for one over the other can be made.

SUMMARY

Progress continues to be made in our understanding of sulcus vocalis from diagnosis to treatment. Novel and promising therapeutic strategies have been recently developed for this condition; however, more data and investigations are needed to improve their accuracy and reproducibility.

Sub-millisecond 2D MRI of the vocal fold oscillation using single-point imaging with rapid encoding

OBJECTIVE

The slow spatial encoding of MRI has precluded its application to rapid physiologic motion in the past. The purpose of this study is to introduce a new fast acquisition method and to demonstrate feasibility of encoding rapid two-dimensional motion of human vocal folds with sub-millisecond resolution.

METHOD

In our previous work, we achieved high temporal resolution by applying a rapidly switched phase encoding gradient along the direction of motion. In this work, we extend phase encoding to the second image direction by using single-point imaging with rapid encoding (SPIRE) to image the two-dimensional vocal fold oscillation in the coronal view. Image data were gated using electroglottography (EGG) and motion corrected. An iterative reconstruction with a total variation (TV) constraint was used and the sequence was also simulated using a motion phantom.

RESULTS

Dynamic images of the vocal folds during phonation at pitches of 150 and 165 Hz were acquired in two volunteers and the periodic motion of the vocal folds at a temporal resolution of about 600 µs was shown. The simulations emphasize the necessity of SPIRE for two-dimensional motion encoding.

DISCUSSION

SPIRE is a new MRI method to image rapidly oscillating structures and for the first time provides dynamic images of the vocal folds oscillations in the coronal plane.

Multivariate Analysis of Vocal Fold Vibrations in Normal Speakers Using High-Speed Digital Imaging

INTRODUCTION

Little is known about the normal variations in vocal fold vibrations. We conducted a prospective study on normal subjects using high-speed digital imaging (HSDI) to elucidate key parameters regarding age/gender-related normal variations.

METHODS

Forty-six healthy adult volunteers were divided into young (aged ≤35 years) male, young female, elderly (aged ≥65 years) male, and elderly female subgroups. HSDI data of sustained phonation of /i/ at a comfortable pitch and loudness were obtained, and vibratory parameters were calculated using the visual-perceptual rating, laryngotopography, digital kymography, and glottal area waveform. Multivariate analysis was then performed on these parameters to clarify the subgroup-specific key parameters.

RESULTS

Four key parameters were identified from a total of 83: one from visual perceptual rating and three from laryngotopography. Subgroup analyses showed that posterior-to-anterior longitudinal phase difference (PD) and high fundamental frequency (F₀) were specific to young female participants. A low F₀ was specific to young male participants. Large anterior-to-posterior longitudinal PD and its left-right difference were specific to elderly male participants. There were no key parameters for elderly female participants.

CONCLUSIONS

Methods that can assess F₀ and longitudinal PD, such as visual-perceptual rating and laryngotopography, were effective in the evaluation of normal vocal fold vibrations and their variations.

Voice aspects in sulcus coexisting with benign lesions of the vocal folds

The purpose of this study was to measure the clinical profile of patients with sulcus who had concomitant benign lesions such as polyp, oedema, cyst, nodules, or fibrous mass of the vocal fold. We reviewed the medical charts of 38 patients who had a diagnosis of sulcus type 2 or 3 (according to Ford). The patients were classified into two groups. The study group consisted of 16 subjects who had sulcus and associated benign lesion; 22 patients diagnosed with sulcus alone were enrolled in a control group. We analysed psychosocial (Voice Handicap Index-30), auditory-perceptual (GRBAS), acoustic measures and videostroboscopic images. In the study group, the mean VHI-30 scores of all subscales ranged from moderate to severe handicap. The difference between groups was significant on the emotional (p = 0.004) and physical (p = 0.007) subscales. On GRBAS scale, the majority of patients from both groups exhibited mild hoarseness, breathiness, asthenic or strained voice, although roughness was more frequently rated moderate; the differences between groups were not statistically significant. The most abnormally increased values were achieved for amplitude values of acoustic parameters, but significant difference between groups was found in Soft Phonation Index only (p = 0.049). Concerning glottal closure, the most frequent finding was irregular chink in the study group, and spindle glottic chink in controls; we found significant differences between groups (p = 0.004). In both series of patients, the most frequent abnormal findings were moderately diminished amplitude and moderately restricted mucosal wave, with no significant difference between groups. Patients with sulcus and coexisting benign lesions were more handicapped on the emotional and physical subscales of VHI-30. The most characteristic shape of the glottal gap was irregular chink in the study group, and spindle chink in the control group. Acoustic evaluation of voice showed that the most severe disturbances affected amplitude parameters. The clinical characteristics indicated that the presence of sulcus primarily determines the quality of voice, and that additional benign pathologies do not drastically affect further voice deterioration. The coexistence of secondary benign vocal fold lesions aggravates the difficulties in making a preoperative diagnosis of sulcus. It is important to clinically suspect the possibility of coexistent sulcus to plan the correct treatment and obtain better voice outcomes.

Clinical characteristics of singers attending a phoniatric outpatient clinic

Purpose: Studies suggest that singers are over-represented in voice clinics and present a high risk of developing voice disorders. This retrospective study aims to describe the characteristics of 78 singers consulting a phoniatrician.Methods: In their medical files, data related to age, gender, occupational status, singing training, musical style, voice complaint, diagnosis, voice-quality grading (GRBAS) and treatment were gathered.Results: The patients were mostly female singers (87%). Non-professional singers (semi-professional included) represented 64%, professional singers 25% and students of singing 11%. The majority of singers were choristers (27%) and 22% were classical-style/oratorio-style singers. Two-thirds of the population had intensive vocal activity in speech or singing. Vocal endurance, somatosensory signs and difficulties with high pitches were the most frequent symptoms. Among the patients, 79% presented with singing-voice disorders with 85% of these having vocal fold lesions. Generally, their speaking voices were preserved. Vocal-folds nodules were the most prevalent pathology (37%) followed by sulcus (26%) and voice therapy was the main treatment.Conclusions: This study emphasizes the fact that singers have specific voice complaints related to their voice usage. The high occurrence of sulcus and other congenital-lesion suspicions, unusual in the general population consulting an ENT phoniatrician, seems to be rather specific for singers in agreement with the literature.

A Systematic Review on Surgical Treatments for Sulcus Vocalis and Vocal Fold Scar

OBJECTIVES/HYPOTHESIS

Vocal fold sulcus and scars are benign vocal fold lesions that present as a challenge to the laryngologist. A number of different surgical techniques have been proposed, aiming at restoring the lamina propria (LP), closing the glottal gap, or both. This study aimed to provide a systematic review of surgical treatment for sulcus and scar and to propose a new classification for these techniques.

STUDY DESIGN

A literature search using MEDLINE and Google Scholar through August 2020.

METHODS

Data on study design were retrieved and outcomes were classified as acoustic, aerodynamic, self-reported, perceptual, and stroboscopic. Methodological quality was assessed using the MINORs criteria. Each technique was classified as direct, indirect, or combined.

RESULTS

Our search included 31 studies with a total of 617 patients. Direct techniques included dissection, graft interposition, or LP regeneration/scar degradation while indirect techniques aimed for glottal gap closure. Only one article performed a comparison between different types of techniques and only eight studied the five types of outcomes. No superiority of any technique was noted in our analysis. Self-reported outcomes were the most frequently improved.

CONCLUSIONS

There seems to not exist a one-fits-all treatment for this clinical picture and no clear decision-making pattern. A recent trend toward sequential approaches, starting with less invasive procedures, can be observed. Laryngoscope, 2021.

Diagnosis and Treatment of Benign Pediatric Lesions

Dysphonia is common in pediatrics and affects individuals from infancy through their teenage years. Pediatric dysphonia has a variable impact on children, ranging from no impact to a severe social barrier. Although most etiologies are benign, potentially life-threatening causes must be ruled out by direct examination of the larynx. The most common benign lesions of the larynx in pediatrics are vocal nodules, vocal fold polyps, cysts, granulomas, ectasias, sulcus vocalis, and vascular lesions, including hemangioma and postcricoid cushion. Treatment of benign vocal lesions should be tailored to the individual patient and the perceived impact.

Treatment Outcomes of Angiolytic Laser-Assisted Glottoplasty in Patients With Sulcus Vocalis

Objective:

We have been performing glottoplasty using angiolytic laser, including pulsed dye laser (PDL) or potassium titanyl phosphate (KTP) laser, for the treatment of sulcus vocalis. In this study, we retrospectively reviewed the treatment results of sulcus vocalis patients who had undergone glottoplasty using angiolytic laser and evaluated the efficacy and safety of this surgical technique.

Methods:

From January 2008 to April 2016, 79 patients with sulcus vocalis who underwent angiolytic LASER-assisted glottoplasty were enrolled in the study.

Results:

Of the 79 patients who participated in this study, 55 were male, and 24 were female. PDL was used for glottoplasty in 68 patients, and KTP was used in the remaining 11 patients. Seventy-seven patients underwent surgery for bilateral vocal cord lesions, and only 2 patients underwent surgery for unilateral vocal cord lesion. After glottoplasty using angiolytic laser, most patients showed continuous improvement of the GRBAS (grade, roughness, breathiness, asthenia, strain) score and Voice Handicap Index score until 6 months after the operation. In addition, we observed improvement of objective voice indices such as noise to harmonic ratio, jitter, shimmer, and maximal phonation time postoperatively.

Conclusions:

Based on these results, we confirmed the efficacy and safety of glottoplasty using angiolytic laser in sulcus vocalis patients. Further studies are needed to confirm appropriate laser settings such as frequency of treatments and total energy delivered to the lesion. Also, multi-institutional studies are needed to confirm the efficacy and safety of the operation.

Pathological sulcus vocalis: treatment approaches and voice outcomes in 36 patients

PURPOSE

This is a retrospective study to evaluate the results of surgical treatment of patients with pathological sulcus vocalis.

METHODS

Thirty-six patients with pathological sulcus underwent surgery and in 33 cases were performed additional injection laryngoplasty. The pre- and postoperative evaluation of patients included the GRBAS scale, stroboscopic, and objective acoustic voice assessment. The Voice Handicap Index questionnaire (VHI-30) was also used and the scores were obtained from 33 patients.

RESULTS

The stroboscopic evaluation showed significant improvement of amplitude, mucosal wave, and glottal closure after treatment (p < 0.001). The VHI-30 scores decreased considerably indicating improvement due to the treatment for all aspects measured by VHI (p < 0.05, or p < 0.01). In all domains of GRBAS scale, the differences between preoperative and postoperative assessment were statistically significant (p < 0.001). We observed a significant change in Shim and APQ parameters (p < 0.05). Improvement was also observed in the sAPQ parameter, but it was not statistically significant (p = 0.051). For the remaining acoustic parameters, no changes were observed.

CONCLUSIONS

The surgical procedure with supplementary injection laryngoplasty of the vocal folds is a good treatment option for pathological sulcus vocalis. The post-treatment self-assessment indicates the significant improvement in VHI, just as perceptual-acoustic evaluation of voice does. Patients with pathological sulcus frequently present with amplitude disturbances, what explains their significant improvement after treatment.

Coexisting Vocal Fold Polyps and Sulcus Vocalis: Coincidence or Coexistence? Characteristics of 14 Patients

OBJECTIVE

The study aimed (1) to evaluate the prevalence of sulcus vocalis (SV) coexisting with vocal fold polyp (SV-VFP), and (2) to determine the effect of their coexistence on voice quality.

STUDY DESIGN

This is a retrospective cohort study in a tertiary referral center.

METHODS

The medical records of all patients who underwent micro direct laryngoscopy due to VFPs between January 2013 and April 2015 were reviewed. Patients with SV-VFP were identified and data of their demographics, medical history, habits, preoperative and intraoperative laryngeal findings, and pre- and postoperative GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score, and compared with the data of patients with solitary VFPs (S-VFPs).

RESULTS

Eighty-nine patients were diagnosed with VFPs, 14 (15.7%) of whom were diagnosed with SV-VFPs. Patients with SV-VFPs had significantly lower incidence of concurrent leukoplakia (P = 0.01), higher incidence of contralateral vocal fold lesions (P = 0.04), increased voice roughness score postoperatively (P = 0.01) on the GRBAS score, and had a lower rate of cigarette smoking (P = 0.02) compared with patients with S-VFPs.

CONCLUSIONS

The possibility of a hidden SV should be considered when detecting VFPs, particularly in patients with contralateral vocal fold lesions and without cigarette smoking history. Because the group of patients with SV-VFP presented with unique features, we suspect that the coexistence of VFPs and SVs is not incidental and that SVs may contribute to the formation of VFPs, possibly by alternating glottic airflow.

Secondary submucosal vocal cyst following pulsed dye laser application for sulcus vocalis

CONCLUSION

Submucosal vocal cyst can occur as a distinct long-term sequelae following pulsed dye laser (PDL) application for sulcus vocalis. It is recommended that the cyst lesion should be surgically removed for treatment. Optimal and precise irradiation of PDL is considered important to avoid the development of a such complication.

OBJECTIVE

After several years of clinical practice and an extended period of follow-up of the patients who received PDL application in treating sulcus vocalis, the authors have encountered several cases of secondary submucosal vocal cyst development. Therefore, this study aims to investigate this late complication following PDL laryngeal surgery.

METHODS

Patients who developed secondary submucosal vocal cyst after last PDL laryngeal surgery between March 2008 and January 2016 were analyzed after retrospectively reviewing clinical and operative data.

RESULTS

There were a total 11 patients who had been identified as presenting secondary submucosal vocal cyst among 186 patients who underwent PDL laryngeal surgery (5.9% incidence). All five patients who received surgery showed complete resolution and were free of symptoms. The remaining six patients were closely observed with conservative measures, with only one patient who showed resolution of the cyst.

Characterization of Vocal Fold Vibration in Sulcus Vocalis Using High-Speed Digital Imaging

PURPOSE

The aim of the present study was to qualitatively and quantitatively characterize vocal fold vibrations in sulcus vocalis by high-speed digital imaging (HSDI) and to clarify the correlations between HSDI-derived parameters and traditional vocal parameters.

METHOD

HSDI was performed in 20 vocally healthy subjects (8 men and 12 women) and 41 patients with sulcus vocalis (33 men and 8 women). Then HSDI data were evaluated by assessing the visual-perceptual rating, digital kymography, and glottal area waveform.

RESULTS

Patients with sulcus vocalis frequently had spindle-shaped glottal gaps and a decreased mucosal wave. Compared with the control group, the sulcus vocalis group showed higher open quotient as well as a shorter duration of the visible mucosal wave, a smaller speed index, and a smaller glottal area difference index ([maximal glottal area - minimal glottal area]/maximal glottal area). These parameters deteriorated in order of the control group and Type I, II, and III sulcus vocalis. There were no gender-related differences. Strong correlations were noted between the open quotient and the type of sulcus vocalis.

CONCLUSIONS

HSDI was an effective method for documenting the characteristics of vocal fold vibrations in patients with sulcus vocalis and estimating the severity of dysphonia.

Effect of voice therapy in sulcus vocalis: A single case study

BACKGROUND

Sulcus vocalis is a structural deformity of the vocal ligament. It is the focal invagination of the epithelium deeply attaching to the vocal ligament. There is a dearth of literature on the outcome of voice therapy in sulcus vocalis condition.

OBJECTIVE

The primary objective of this study was to document voice characteristics of sulcus vocalis and the secondary objective was to establish the efficacy of voice therapy in a patient with sulcus vocalis.

METHOD

A trial of voice therapy was given to the client who was diagnosed as having sulcus vocalis. Boon's facilitation techniques were used in voice therapy along with other techniques such as breath holding and push and pull approach prior to surgery. Acoustic, aerodynamic, perceptual, quantitative measures of voice quality and self-rating measurements were performed before and after voice therapy.

RESULTS

Improvement was noticed in 10/10 acoustic, 4/4 aerodynamic, perceptual, dysphonia severity index and voice handicap index scores, which hinted that voice therapy can be an option critically for clients with sulcus vocalis in the initial stage.

CONCLUSION

Voice therapy showed promising improvement in the study and it must be recommended as the initial treatment option before any surgical management.

Sulcus Vocalis (Type III): Prevalence and Strobovideolaryngoscopy Characteristics

OBJECTIVES

The reported prevalence of sulcus vocalis (SV)/type III, a pathologic groove in the vibratory margin of the vocal fold, varies greatly in the literature. Difficulties in visualizing the defect and a variety of descriptions have complicated the evaluation of SV. The objective of this study was to determine the prevalence of SV by reviewing strobovideolaryngoscopy (SVL) examinations in subjects with and without dysphonia.

STUDY DESIGN

Retrospective chart review.

METHODS

Charts and SVL images were reviewed for subjects with and without dysphonia and analyzed using standard statistical techniques.

RESULTS

SVL images were reviewed for 94 nondysphonia subjects and 100 dysphonia subjects. For all subjects, 19.6% had type I, 2.1% had type II, and 5.7% had type III/SV. Per vocal fold, 14.7% had type I, 1.3% had type II, 3.1% had type III/SV and 13.1% had scar. The prevalence of SV per subject was not significantly different between the two groups (8% of dysphonia subjects, 3.2% of nondysphonia subjects). Male gender, decreased amplitude, decreased waveform, and hypodyamic motion were significantly higher in the dysphonia SV subjects compared with the non-SV subjects. All other SVL characteristics were not significantly different in subjects with SV compared with non-SV subjects.

CONCLUSIONS

We report a prevalence of SV/type III at 3.1% (per vocal fold) and 5.7% (per subject). Higher frequencies of male gender and waveform abnormalities were seen in the dysphonia SV subjects only. There were no significant differences in nondysphonia subjects with or without SV.

Videolaryngostroboscopy versus microlaryngoscopy for the diagnosis of benign vocal cord lesions: a prospective clinical study

The aim of this study is to prospectively compare rigid videolaryngostroboscopy with microlaryngoscopy for the diagnosis of benign vocal cord lesions. Eighty-five adult patients with benign vocal cord lesions were evaluated with videolaryngostroboscopy and later underwent microlaryngoscopy. During microlaryngoscopy, systematic examination of the glottis was conducted, including careful inspection and meticulous palpation of the vocal cords from anterior commissure to arytenoids. Preoperative and intraoperative diagnoses were analyzed. One hundred and forty-one lesions were diagnosed preoperatively with rigid videolaryngostroboscopy in 85 patients. Microlaryngoscopy revealed a total of 199 lesions in these patients, demonstrating a 41.1 % higher diagnostic yield. Forty-five (77.6 %) of the 58 additional lesions involved structural abnormalities, including sulcus vocalis, microwebs, vascular ectasia, mucosal bridges, and anterior web. The preoperative diagnosis was consistent with the postoperative diagnosis in only 29 patients (34.2 %). For the rest of the patients (n = 56, 65.8 %), the preoperative diagnosis was either changed, or new lesions were identified during microlaryngoscopy. Intraoperative diagnosis of benign vocal cord lesions differs significantly from preoperative diagnosis, regarding both the type and number of lesions present. A large proportion of patients diagnosed with videolaryngostroboscopy have additional lesions, particularly structural abnormalities. Precise inspection and palpation of vocal cords are thus essential during microlaryngoscopy.

Vocal fold scars: current concepts and future directions. Consensus report of the Phonosurgery Committee of the European Laryngological Society

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

Use of Pulsed Dye Laser in the Treatment of Sulcus Vocalis

Objective

The pulsed dye laser (PDL) has been shown to be effective in the treatment of hypertrophic scars and keloids in dermatology. On the basis of histopathologic similarities between sulcus vocalis and scar tissue and numerous reports on the treatment of laryngeal lesions, especially scar tissue, with PDL, we evaluated the efficacy of treating sulcus vocalis with PDL. We named this surgical procedure PDL glottoplasty.

Study Design

Case series with planned data collection.

Setting

A university-based, tertiary care medical center.

Subjects and Methods

This study was conducted on 25 patients diagnosed with sulcus vocalis by videostroboscopy at the Gangnam Severance Hospital Otorhinolaryngology Department between August 2006 and February 2012. Energy delivery was fixed at 0.75 Joules (J) per pulse, and each vocal fold was administered 60 to 110 pulses (average 72.5 pulses) during each procedure. Aerodynamic, stroboscopic, and acoustic voice analyses were performed pre- and postoperatively.

Results

Although assessment was necessarily subjective, our study indicated that vocal folds showed decreased stiffness and improved mucosal wave properties after treatment, resulting in improved vibration and dysphonia. In the objective assessments, most patients who underwent PDL glottoplasty showed improvement in several postoperative voice analysis indices. The differences between preoperative and some postoperative voice parameter indices were statistically significant.

Conclusion

We found PDL glottoplasty to be beneficial in the treatment of sulcus vocalis. Objective measurements of voice quality and normalization of vocal fold vibration improved after PDL treatment in most cases. Our results warrant further studies with larger numbers of participants and longer follow-up periods.

Voice Outcomes following the Gray Minithyrotomy

Objectives:

Most practitioners have limited treatment options for vocal fold scar and sulcus vocalis. The Gray minithyrotomy (GMT) is a surgical procedure for the treatment of these conditions, although limited objective data exist regarding voice outcomes. This study compares the quantified subjective and visual perceptual outcomes following GMT for the treatment of vocal fold scar and sulcus vocalis.

Methods:

We performed a retrospective review of patients who underwent GMT in a single institution. Patient-reported satisfaction, Voice Handicap Index–10 scores, results of video perceptual analysis, and complications were recorded.

Results:

Sixteen patients underwent GMT for phonotraumatic or postoperative scar (11), radiation-induced scar (3), or sulcus vocalis (2). Seven underwent bilateral operations. Follow-up data were available for 12 patients. Eight patients had 2 or more failed surgical interventions before GMT. Seven of the 13 procedures resulted in a self-reported improvement. Although the mean preoperative Voice Handicap Index–10 score (30.6) across all patients did not decrease after the operation, 6 of the 13 GMT procedures resulted in improvement (mean decrease, 7.5). Complications, encountered in 5 patients, included ecchymosis, neck abscess, tongue numbness, wound dehiscence, and aspiration pneumonia.

Conclusions:

The GMT is a viable treatment for severe vocal fold scar and sulcus vocalis. Our results show improvement in half of a cohort that was marked by previous failures at improving voice. These results point to the recalcitrant nature of voice difficulties in treating vocal fold scar and sulcus, and may properly guide clinicians and patients in their expectations following this infrequently used technique.

Cause of vocal fold scar

PURPOSE OF REVIEW

The prolonged debilitation, loss of income, and decrement in quality of life caused by vocal fold scar is exacerbated by our inability to successfully treat this difficult problem. As technology focuses on developing innovative treatments, we need to fully appreciate and understand the mechanisms giving rise to glottal scar, on both a macroscopic and microscopic level. This review examines recent literature pertaining to the gross and molecular mechanisms which give rise to vocal fold scar.

RECENT FINDINGS

Mechanisms of vocal fold scar production have been examined in both macroscopic and microscopic detail. Trauma and injury involving any aspect of the lamina propria, particularly the deeper layers, may result in epithelial tethering and scar formation. At the molecular level, early inflammatory cytokines activate and recruit fibroblasts which then drive the fibrotic cascade. Transforming growth factor-β enhances fibrosis and is balanced by tissue matrix metalloproteinases and hepatocyte growth factor activity. Molecular signaling offers novel opportunities to intervene in scar formation.

SUMMARY

New work investigating the cause of vocal fold scar identifies complex molecular processes leading to fibrosis in the lamina propria. Improved mechanistic understanding offers insight into prevention strategies and possible targets for antifibrotic therapies that may help prevent or treat this debilitating condition.

Implantation of gelatin sponge combined with injection of autologous fat for sulcus vocalis

OBJECTIVE

To evaluate the effectiveness of gelatin sponge implantation combined with the injection of autologous fat for the treatment of sulcus vocalis.

STUDY DESIGN

Prospective cohort study.

SETTING

The research was conducted at the Eye, Ear, Nose, and Throat Hospital of Fudan University.

SUBJECTS AND METHODS

Twelve cases of sulcus vocalis were treated. The fibrotic tissue was dissected and a gelatin sponge was implanted into the affected vocal fold followed by injection of autologous fat. Videostroboscopy, maximum phonation time (MPT), and acoustic data were completed before and after surgery.

RESULTS

One month after surgery, the affected vocal fold displayed mild swelling, without evidence of a sulcus and with satisfactory glottal closure. Three months later, vocal vibration and mucosal wave were improved with the vocal fold displaying a more normal shape. Although voices did not achieve complete normalcy, the patients exhibited a better voice, with improved fundamental frequency, jitter, shimmer, normalized noise energy, and a significantly longer maximum phonation time (P < 0.05).

CONCLUSION

Implantation of gelatin sponge combined with injection of autologous fat can be used to treat sulcus vocalis. The absorbable gelatin sponge can be used to fill the superficial lamina propria temporarily to prevent the readhesion of the detached mucosa at the bottom of the sulcus to the underlying tissue, while the injected fat adequately diminishes the insufficient glottal closure.

Sulcus configurations of vocal folds during phonation

CONCLUSION

A detailed understanding of clinical and voice characteristics will help to differentiate sulcus configuration and plan rational management strategies for each type.

OBJECTIVES

To investigate the clinical and voice characteristics of patients with sulcus configuration of vocal folds during phonation.

PATIENTS AND METHODS

A total of 146 patients with bilateral sulcus configuration of vocal folds were enrolled in this study. Based on videostroboscopic findings, patients were classified into three groups: physiologic sulcus configuration group (type I), pathologic sulcus configuration group, including sulcus vergeture (type II), and sulcus vocalis (type III). Voice analyses were obtained from a recorded speech sample.

RESULTS

Thirty-two patients (21.9%) were type I, 61 (41.8%) were type II, and 53 (36.3%) were type III. Different sulcus configuration groups had significantly different roughness and mean fundamental frequency. Type III was significantly different from type I and type II in grade, breathiness, mean flow rate, subglottic pressure, maximum phonation time, Jitter%, and harmonics to noise ratio. The pathologic sulcus showed distinctive features in electroglottograph waveform.