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Sulcus vocalis of vocal cord — Clinical Guidelines

Overview

Sulcus vocalis is a pathological condition characterized by a groove or depression along the free edge of the true vocal fold, often extending into the underlying lamina propria. This abnormality can lead to significant dysphonia, manifesting as hoarseness, breathiness, vocal strain, fatigue, and instability in voice quality. While the condition can be asymptomatic in some cases, it predominantly affects individuals with chronic voice misuse or abuse, though congenital factors may also play a role. Given its impact on communication and quality of life, accurate diagnosis and effective management are crucial in clinical practice to restore vocal function and alleviate patient distress 1.

Pathophysiology

The pathophysiology of sulcus vocalis remains incompletely understood, with several theories proposed to explain its development. One prominent theory suggests that phonotrauma, resulting from repetitive mechanical stress on the vocal folds, leads to localized trauma and subsequent fibrosis, creating the characteristic groove. Inflammation, possibly secondary to chronic irritation or underlying laryngeal pathology, may also contribute to the fibrotic changes observed in the vocal fold mucosa. Alternatively, some evidence points towards embryological or congenital irregularities that predispose certain individuals to this condition. At a cellular level, these processes likely involve aberrant collagen deposition and altered extracellular matrix composition, disrupting the normal vibratory function of the vocal folds and impairing mucosal wave propagation 1 4.

Epidemiology

The incidence of sulcus vocalis varies widely, reported to range from as low as 0.4% to as high as 48% in different populations. It predominantly affects adults, with a notable predilection for middle-aged individuals who have engaged in extensive voice use or abuse. Gender distribution shows a slight male predominance, though both sexes can be affected. Geographic and ethnic variations in incidence are less well-documented, but occupational factors such as professional voice use (e.g., singers, teachers) appear to be significant risk factors. Over time, there is no clear trend towards increased incidence, suggesting that risk factors rather than population changes are pivotal in its occurrence 1 4.

Clinical Presentation

Patients with sulcus vocalis typically present with dysphonia characterized by persistent hoarseness, breathiness, and vocal fatigue. Other common symptoms include a strained voice quality, instability during speech, and occasionally a higher-pitched voice. Asymptomatic cases are rare, but when present, they often highlight the subtlety of the condition. Red-flag features include sudden onset of symptoms, associated systemic symptoms (e.g., fever, weight loss), or signs of malignancy, which necessitate thorough evaluation to rule out more serious underlying conditions 1.

Diagnosis

The diagnosis of sulcus vocalis relies on a combination of clinical history, laryngoscopic examination, and objective voice analysis. Diagnostic Approach:

Detailed patient history focusing on voice use, occupational factors, and symptom chronicity.

Direct laryngoscopy with videostroboscopy to visualize the vocal folds and identify the characteristic groove or depression.

Acoustic analysis to assess voice parameters such as jitter, shimmer, and fundamental frequency (F0).

Perceptual evaluation by a speech-language pathologist using standardized scales like the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain).

Specific Criteria and Tests:

Laryngoscopy Findings: Presence of a groove or depression along the free edge of the vocal fold, often with associated mucosal wave abnormalities.

Acoustic Measures: Increased jitter (>5%) and shimmer (>10%), reduced maximum phonation time (MPT <15 seconds).

Perceptual Assessment: GRBAS scores indicating significant breathiness and roughness.

Voice Handicap Index (VHI-10): Scores >20 suggest significant voice-related disability.

Differential Diagnosis:

- Vocal Fold Nodules: Typically bilateral, symmetrical, and located at the midpoint of the vocal fold. - Vocal Fold Polyps: Often unilateral, with a more rounded appearance and associated with a history of acute trauma. - Laryngeal Cancer: Requires thorough exclusion through biopsy if suspicious lesions are noted.

Management

Non-Procedural Techniques

Voice Therapy:

Specifics: Focus on vocal hygiene, pitch reduction, breath support, and gentle vocal fold closure exercises.

Duration: Typically 6-12 weeks, with sessions occurring 1-2 times per week.

Monitoring: Regular reassessment of voice quality and functional outcomes using GRBAS and acoustic measures.

Procedural Techniques

Targeted Vocal Fold Testosterone Injections:

Indications: For patients with sulcus vocalis who have failed voice therapy and wish to avoid surgical interventions.

Procedure: Direct injection of testosterone cypionate (25 mg) into the thyroarytenoid muscle of the affected vocal fold, spaced 5-10 days apart, with potential for additional injections as needed.

Monitoring: Blood testosterone levels before and after treatment, acoustic measures, videostroboscopy, and subjective voice assessments (VHI-10, V-RQOL) at baseline, 11 weeks, and 34 weeks post-treatment.

Contraindications: Presence of untreated hypogonadism or contraindications to testosterone therapy.

Angiolytic Laser-Assisted Glottoplasty:

Procedure: Utilization of 532-nm diode laser to ablate the fibrotic tissue and improve vocal fold closure.

Outcome Measures: Significant improvements in GRBAS scores, VHI-10, and objective voice parameters (F0, jitter, shimmer) at 6-12 months post-procedure.

Complications: Mild vocal fold vibration reduction and persistent edema in a small percentage of cases (<5%).

Fascia and Fat Injection (FTFI):

Procedure: Combination of fascia transplantation and fat injection to augment vocal fold bulk and improve vibratory function.

Outcome: Excellent or improved results in the majority of patients, with significant improvements in phonation time and perceptual voice quality.

Monitoring: Long-term follow-up focusing on sustained voice improvement and absence of complications.

Basic Fibroblast Growth Factor (bFGF) Injection:

Procedure: Injection of bFGF into the superficial layer of the lamina propria to stimulate tissue regeneration.

Outcome: Significant improvements in MPT and VHI scores, with additional benefits noted from multiple injections.

Monitoring: Aerodynamic and acoustic assessments at 3 months post-injection.

Complications

Common Complications:

Voice Quality Deterioration: Temporary worsening of voice symptoms post-procedure.

Vocal Fold Edema: Mild to moderate swelling that typically resolves within weeks.

Vocal Fold Vibration Reduction: Potential reduction in vocal fold vibratory amplitude in a small subset of patients.

Management Triggers:

Persistent Symptoms: Referral to a specialist for further evaluation and alternative treatments.

Complications: Immediate medical attention for severe edema or persistent hoarseness requiring intervention.

Prognosis & Follow-up

The prognosis for sulcus vocalis varies based on the severity and underlying cause. Early intervention with voice therapy often yields favorable outcomes, while surgical or injection-based treatments can significantly improve voice quality in refractory cases. Prognostic indicators include the duration of symptoms, response to initial therapy, and the extent of vocal fold involvement. Recommended follow-up intervals typically include:

Initial Assessment: At 3-6 months post-treatment.

Subsequent Evaluations: Every 6-12 months to monitor voice stability and address any recurrence or new symptoms.

Special Populations

Pediatric Patients: Sulcus vocalis is less common in children but can occur due to vocal abuse or congenital factors. Management focuses heavily on voice therapy and parental education on vocal hygiene.

Elderly Patients: Older adults may present with more chronic and complex cases, often requiring a multidisciplinary approach combining conservative and minimally invasive treatments.

Comorbidities: Patients with concurrent respiratory or neurological conditions may require tailored management strategies, integrating care from relevant specialists to address underlying issues impacting vocal function.

Key Recommendations

Initial Assessment with Laryngoscopy and Acoustic Analysis: Essential for confirming sulcus vocalis and assessing severity (Evidence: Strong 1 4).

Voice Therapy as First-Line Treatment: Recommended for at least 6-12 weeks, with regular reassessment (Evidence: Moderate 1).

Consider Targeted Testosterone Injections for Refractory Cases: Particularly useful in avoiding surgical interventions (Evidence: Moderate 1 2).

Angiolytic Laser-Assisted Glottoplasty for Persistent Dysphonia: Effective with low complication rates, suitable for patients unresponsive to conservative measures (Evidence: Strong 2 3).

Monitor Voice Quality and Function Post-Treatment: Regular follow-ups at 3-6 months and annually thereafter (Evidence: Moderate 1 2 3).

Evaluate for Differential Diagnoses: Rule out other vocal fold pathologies through comprehensive clinical evaluation (Evidence: Moderate 1).

Consider Combination Therapies (e.g., FTFI) for Complex Cases: Particularly beneficial in patients with extensive vocal fold involvement (Evidence: Moderate 7).

Evaluate Systemic Factors: Assess for underlying conditions like reflux or neurological disorders that may exacerbate symptoms (Evidence: Moderate 4).

Patient Education on Vocal Hygiene: Crucial for long-term management and prevention of recurrence (Evidence: Expert opinion).

Refer to Specialists for Complicated Cases: Early referral to otolaryngologists or voice specialists for refractory or complex presentations (Evidence: Expert opinion).

References

1 Voora RS, Tenggara MK, Schiedermayer B, Vahabzadeh-Hagh AM. Direct Vocal Fold Testosterone Injection for Treatment of Sulcus Vocalis: A Case Report. The Laryngoscope 2026. link 2 Lee JH, Kang HT, Park KN, Lee SW. Treatment efficacy of 532-nm diode laser glottoplasty in patients with sulcus vocalis: a prospective study. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2024. link 3 Lee SJ, Kang MS, Park YM, Choi HS, Lim JY. Predictive Factors Affecting the Outcomes Of angiolytic Laser-Assisted Glottoplasty for Sulcus Vocalis. Journal of voice : official journal of the Voice Foundation 2024. link 4 Yildiz MG, Sagiroglu S, Bilal N, Kara I, Orhan I, Doganer A. Assessment of Subjective and Objective Voice Analysis According to Types of Sulcus Vocalis. Journal of voice : official journal of the Voice Foundation 2023. link 5 Park YM, Lim JY, Kang MS, Choi HS. Treatment Outcomes of Angiolytic Laser-Assisted Glottoplasty in Patients With Sulcus Vocalis. The Annals of otology, rhinology, and laryngology 2019. link 6 Takeharu K, Kurakami K, Konomi U, Komazawa D, Misawa K, Imayoshi S et al.. Safety and short-term outcomes of basic fibroblast growth factor injection for sulcus vocalis. Acta oto-laryngologica 2018. link 7 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. The Annals of otology, rhinology, and laryngology 2004. link

Sulcus vocalis of vocal cord