What is the diagnosis and treatment for a patient with sulcus vocalis, a voice disorder characterized by a groove on the vocal cord?

Sulcus Vocalis: Diagnosis and Management

What is Sulcus Vocalis?

Sulcus vocalis is a benign structural abnormality characterized by a longitudinal groove along the free edge of the vocal fold that disrupts normal vocal fold vibration, causing breathy and effortful dysphonia. 1 The condition interferes with glottic closure and the mucosal wave pattern, resulting in voice fatigue, hoarseness, and breathiness. 2, 3

Classification

Sulcus vocalis is categorized into three types based on depth and involvement 4:

• Type I (Physiologic sulcus): Superficial groove that may be considered nearly normal and often asymptomatic 5, 4
• Type IIa (Sulcus vergeture): Deeper groove involving the lamina propria layers, causing more significant vocal dysfunction 4
• Type IIb (Sulcus pouch): Represents an open cyst configuration with the most severe impact on voice 4

Among asymptomatic individuals with sulcus vocalis, Type I predominates (78%), with Type II accounting for 22%. 5

Diagnosis

When to Perform Laryngoscopy

Clinicians should perform diagnostic laryngoscopy, or refer to a specialist who can, when dysphonia fails to resolve within 4 weeks or immediately if a serious underlying cause is suspected. 1 Laryngoscopy may be performed at any time based on clinical judgment. 1

Diagnostic Challenges

Diagnosis can be difficult even with videostroboscopy, and definitive identification sometimes requires examination under general anesthesia with suspension microlaryngoscopy. 4 Vocal fold palpation during microlaryngoscopy remains the gold standard for confirming the diagnosis and assessing the depth of involvement. 6

Key Laryngoscopic Findings

Look for 4, 3:

• Longitudinal groove parallel to the free edge of the vocal fold
• Incomplete glottal closure during phonation
• Reduced or absent mucosal wave amplitude on stroboscopy
• Stiffness of the vocal fold free edge

What NOT to Do Before Laryngoscopy

Do not obtain CT or MRI imaging prior to visualizing the larynx in patients with isolated voice complaints. 1 Laryngoscopy is the primary diagnostic modality, and imaging is unnecessary in most cases. 1

Do not prescribe antireflux medications, corticosteroids, or antibiotics for isolated dysphonia without first visualizing the larynx. 1 These medications are not indicated for sulcus vocalis specifically and should not be used empirically. 1

Treatment Approach

Initial Management: Voice Therapy First

Clinicians should advocate voice therapy as the primary treatment for sulcus vocalis before considering surgical intervention. 1 Voice therapy should be provided by a certified speech-language pathologist and must be preceded by laryngoscopic diagnosis with documentation communicated to the therapist. 1

The rationale for prioritizing voice therapy 2, 6:

• Treatment should start with voice therapy and continue as long as the patient shows progress
• Voice therapy addresses the secondary hyperkinetic phonatory pattern that develops as compensation for glottic insufficiency 2
• Surgical results are often disappointing and unpredictable 2, 4

When Surgery May Be Considered

Surgery should only be discussed after voice therapy has been exhausted without adequate improvement. 2 Patients must be extensively counseled that surgical outcomes are often disappointing, with the primary realistic goal being increased vocal loudness rather than complete voice normalization. 4

Surgical Options (When Conservative Management Fails)

Multiple surgical techniques have been described, but no gold standard surgical approach exists, and results are diverse with no strong evidence favoring one technique over another. 6 The most commonly reported approaches include 2, 6:

• Sulcus excision: Longitudinal incision with undermining and removal of the sulcus tissue, though this often fails to restore physiological phonation despite apparent voice improvement 2
• Slicing mucosa technique: Creation of inferiorly based mucosal slices 2
• Excision combined with medialization thyroplasty (Type I): Used for severe glottal gaps to improve closure 2
• Injection laryngoplasty: Bulking agents to augment vocal fold mass, though results are generally inferior to excision techniques 2

The combination of excision surgery followed by postoperative voice therapy has shown the best results in clinical series. 2

Critical Counseling Points

Before any surgical intervention, patients must understand 2, 4:

• Treatment is demanding and long-lasting
• Results are often unpredictable and may be disappointing
• The primary achievable goal is typically increased loudness, not complete voice restoration
• Postoperative voice therapy is essential for optimal outcomes

Special Considerations

Asymptomatic Patients

Approximately 78% of asymptomatic individuals with sulcus vocalis have Type I sulci and may exhibit only slight changes in vocal quality and roughness on objective assessment. 5 These patients do not require treatment unless symptoms develop or quality of life is affected.

Associated Conditions

Different benign laryngeal conditions may coexist with sulcus vocalis, and recognizing when to treat these associated findings is important for comprehensive management. 6

Follow-Up and Documentation

Clinicians should document resolution, improvement, or worsening of dysphonia symptoms and changes in quality of life after treatment or observation. 1 Follow-up should continue until the dysphonia has improved, resolved, or the underlying condition has been appropriately managed. 1