Sulcus Mucosal Slicing Technique

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Sulcus mucosal slicing technique

ARTICLE in CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY OCTOBER 2010

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Sulcus mucosal slicing techniquePaulo Pontes

aand Mara Behlau

b

Introduction and historical notes

The sulcus was first described by the Italian anatomist

Giacomini, in 1892 [1], and described repeatedly since

then in very few publications [24]. However, with the

advent of better diagnostic tools and dissemination

of knowledge, its identification has been extended

[59,10,11].

There are no data on the incidence of this alteration. The

literature has been exploring two main causes: a conge-

nital deviation/disorder or as a result of trauma. The

congenital disorder cause was described early in the

literature [2], even with a postulation of faulty genesis

of the fourth and sixth branchial arches[6]; degeneration

of fibroblasts in the macula flavae similar to age-relateddegeneration of vocal folds [8]. Four familial cases [12]

and monozygotic twin sisters [13]have been described.

Some authors consider that the cause may be due to a

repetitive trauma [5,14], infection or as a rupture of a

vocal cyst[6,15]; other authors admit more than one cause

[46,16] and even speculate that both causes can be

complementary [17].

Our group considers that sulcus has a congenital cause;

however, it is only one of many anatomical variations that

may occur at the vocal fold level. German authors[2,18],

in the first half of the 20th century, have already pointed

out that some of these alterations produced no interfer-

ence with the vital laryngeal function but could even-

tually hamper the phonatory function of the larynx.

These were called minor congenital anomalies. However,

due to their frequent occurrence and no impact in several

cases, they cannot be considered anomalies or malfor-

mations. Our proposal is that these alterations can be

considered anatomical variations, broadly classified into

four morphological categories: sulcus, cysts, mucosal

bridge and microdiaphragms (Table 1) [19].

Taking into consideration the German proposal, we

updated the term by replacing anomaly or malformation

with structural alterations; actually, minor structural altera-

tions. These differentiated anatomical variations are theutmost expression of a large possibility of deviations, most

of them without a specific morphological identity and, for

this reason, called undifferentiated alterations. These

variations at lamina propriae level also introduce changes

at the vascular network, which loses the classical parallel or

almost parallel distribution in the free edge of the vocal

fold, with dichotomic small caliber vessels at the mucosa.

The altered vascular trajectory should not be considered as

ectasias, varices or other vascular diseases but simply

vascular dysgenesia due to the congenital anatomical

variation of the vocal fold cover [20].

aDepartment of Otorhinolaryngology-Head and NeckSurgery and bDepartment of Speech LanguagePathology and Audiology, Federal University of SaoPaulo, Universidade Federal de Sao Paulo (UNIFESP),

and professor at Center of Voice Studies CEV(Centro Estudos da Voz), Sao Paulo, Brazil

Correspondence to Paulo Pontes, MD, Rua Diogo deFaria 171, Sao Paulo, SP 04037000, BrazilTel: +55 11 5549 2188; fax: +55 11 5549 2188;e-mail:[email protected].

Current Opinion in Otolaryngology & Head andNeck Surgery 2010, 18:512520

Purpose of review

To present the accurate surgical indication for the slicing mucosal technique, the case

selection, surgical aspects, rehabilitation concerns, and the characteristics of

immediate and long-term outcomes.Recent findings

The literature is still scarce; few cases are submitted to the slicing mucosa technique

due to its specific indication; an alternative procedure was designed for cases where

mucosal movement is strongly reduced, the inner section of the vocal ligament or

submucosal scar tissue, which can eventually be associated with fat inclusion. Some

selected cases may require thyroplasty type III to optimize functional results.

Summary

Slicing technique is an aggressive powerful resource for the surgical treatment of

severe cases of sulcus striae major, in which mucosal wave is absent and glottic chinkis

moderate to severe; voice is intensely deviated immediately postoperation; vocal

rehabilitation is mandatory and an intensive regimen is usually required for the first

2 months; final results can mostly be achieved up to 6 months.

Keywords

dysphonia, slicing technique, sulcus striae, sulcus vocalis

Curr Opin Otolaryngol Head Neck Surg 18:5125202010 Wolters Kluwer Health | Lippincott Williams & Wilkins1068-9508

1068-9508 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOO.0b013e3283402a3b
mailto:[email protected]://dx.doi.org/10.1097/MOO.0b013e3283402a3bhttp://dx.doi.org/10.1097/MOO.0b013e3283402a3bmailto:[email protected]



The functional impact of a minor structural change

depends on its morphology and on the individual vocal

profile. There is not a direct and simple correlation

between morphology and functional outcome. Besides

the morphological configuration, axiological factors,

personality aspects (extraversion trait), vocal usage, occu-

pational demands and vocal hygiene habits may triggerthe dysphonia. Vocal deviations, besides vocal fatigue

and effort to phonate, can include high-pitched voice,

instability, roughness, breathiness and strain.

Sulcus classificationThe morphological classification of sulcus adopted by us

is as follows: occult sulcus, sulcus striae (or vergeture) and

sulcus pocket.

Occult sulcus

This alteration is solely identified by laryngostroboscopy

during phonation through observation of the mucosal

wave formation. The impact on spoken voice is minimal

and, if present, restricted to vocal range. Dysphonia can

be triggered when vocal loading is enhanced.

Sulcus striae

The term striae (vergeture) was proposed by Bouchayer

et al. [6] in order to characterize vocal fold depressions

similar to skin marks (wrinkles). However, we propose

two variants, the minor and major ones, according to the

distance between the depression lips.

In sulcus striae minor, lips are usually in contact along itswhole surface; the image looks like an incision (Figs 1

and 2). The sulcus striae minor can be unilateral or

bilateral, single or multiple, reduced or extended in

length. Its presence can be better visualized during

inspiratory movement, with open vocal folds and less

light contrast at the sulcus surface. In some cases, it is

identified only during exploratory microlaryngoscopy or

surgery for other lesions. The minor striae can reduce the

mucosal vibration and consequently alter vocal quality;

secondary ipsilateral and contralateral lesions, such as

polyps and edemas, are usually seen.

Sulcus striae major is visualized as a mucosal depression

similar to a groove or a furrow due to the relative distance

between its lips, creating a superior and inferior margin,

the latter usually rigid (Figs 3 and 4). The vocal impact is

related to the depth of the sulcus, which produces a

distorted mucosal wave that can even be absent. Voice

is rough, tense, high-pitched and usually disagreeable,sometimes with a diplophonic component; breathiness

can be severe and even produce phonatory breaks. Con-

trary to the previously presented variant, the sulcus striae

major rarely produces secondary lesions due to lack of

enough glottic closure.

The treatment of this alteration has to consider its main

functional consequence. For discrete cases, vocal reha-

bilitation can lead to stabilization; for severe cases

(reduced or absent mucosal wave and moderate to large

glottic chinks), surgery is usually applied.

Sulcus pocket

Previously named open cyst or sulcus vocalis[6], a sulcus

pocket corresponds to a real cavity in the vocal fold, in

which the lips still preserve contact[21](Figs 5 and 6). Its

presentation is usually like a mucosal bump, similar to a

cyst (a frequent misdiagnosis), as the mucosal opening is

Sulcus mucosal slicing technique Pontes and Behlau 513

Table 1 Classification of sulcus according to Pontes et al. [19], considering other minor structural alterations of the larynx

Minor structural alterationsof vocal fold cover

UndifferentiatedDifferentiated Sulcus Occult

Striae MinorMajor

PocketDeep

Epidermoid cysts Superficial

FistulizedMucosal bridgeLaryngeal microdiaphragm

Vascular dysgenesia

Figure 1 Schematic drawing of a sulcus stria minor



rarely seen in routine examinations. Its mucosal wave hasa better vibratory pattern than the striae sulcus. Glottic

closure can be complete, irregular or with double chink.

Secondary lesions, such as polyps, contralateral reactions,

leukoplakias and chronic laryngitis are frequently associ-

ated. Monochorditis is usually a sign of sulcus pocket

presence at vocal fold level. Voice is usually low-pitched

due to the increase of the vocal fold mass. Dysphonia

degree can vary and be present in a fluctuating fashion;

inflammatory episodes are the main cause of vocal varia-

bility. Vocal rehabilitation is suggested to improve muco-

sal vibration, to reduce secondary lesions and to achieve a

differential diagnosis with vocal fold nodules. Surgery for

sulcus pocket is the deepithelization of the cavity.

Many authors have classified the sulcus with different

criteria, and therefore there is not a correspondence

among them. Table 2 [22,23] presents these classifi-

cations distributed similarly to the anatomical classifi-

cation of Pontes et al. [19]. Ford et al. [11] provided acategorization of three types of sulcus: type I, named

physiological sulcus, is a depression that does not reach

the vocal ligament; type II is a full-length musculomem-

branous vocal fold depression, extending down to the

vocal ligament or further; and type III is a deep focal

indentation of the vocal fold that does not involve the

whole length of the focal fold.

The surgery is an anatomical procedure with a functional

goal. Therefore, a morphologically based classification is

beneficial to design and plan the surgery.

Management of sulcus striaeSeveral surgical techniques to treat sulcus striae have

been proposed, with variable results: sulcus resection

[24], vocal fold augumentation volume through endo-

scopic techniques using collagen [25], fat [26,27,28],

514 Laryngology and bronchoesophagology

Figure 3 Schematic drawing of a sulcus striae major

Figure 4 Sulcus stria major (arrow), under laryngoscopic vision,during inspiration

Figure 5 Schematic drawing of sulcus pocket

Figure 2 Sulcus stria minor (arrow), under laryngoscopic vision,during inspiration



muscle fascia implantation [29], external medialization

via thyroplasty type I [30,31], and laryngoplasty with

tissue transposition[32,33].

In cases with no mucosal wave and cordal vibration (one

mass regimen), with large glottic chinks, the above-men-

tioned techniques are insufficient to produce a better

vocal quality and/or provide vocal endurance. Vocal fold

medialization or sulculectomy will not be able to provide

mucosal pliability and may even introduce more mech-

anical resistance to phonate. Therefore, surgical inter-

ventions may have to be aggressive, as the tissue pres-

ervation rule may not apply here due to the fact that these

patients do not show a normal configuration of the multi-

layered mucosal structure. In these cases, our surgery

option is using the slicing technique [34].

Technical challenges of the slicing mucosatechniqueThere are many technical challenges of the slicing

mucosa technique, some related to the nature of the

alteration and others to the surgeons skills. The goal

of the surgery is to interrupt the longitudinal tensionproduced by the presence of the sulcus, as well as to

promote mucosal vibration by bringing the pliable ven-

tricular face tissue to participate in the sound source.

With this procedure, a triple result can be obtained:

pliability of the mucosa, vibratory tecidual structure

and reduction of glottic chink.

The main technical challenges are listed below:

(1) Visibility (Fig. 7): adequate visual surgical condition

to perform endoscopic approach surgery.

(2) Soft tissue identification (Fig. 8): longitudinal

incision at the vocal fold vestibular face away from

the edge, as close as possible to the laryngeal ven-

tricle, including the available soft tissue.

(3) Main flap procedure (Fig. 9): out from the longi-

tudinal incision, a tissue flap inferiorly based has to

be created with a 2-mm depth from the sulcus

inferior margin; the tissue flap has to be thick to

preserve vascular properties and avoid necrosis; in

all cases vocal ligament will be partially or totally

included; in a few cases some portion of the thyr-

oarytenoid muscle will take part of the flap.

(4) Number of secondary flaps: a minimum of four

different length incisions, perpendicular from the

free edge of the main flap (counter-incisions) have tobe created in order to produce at least three small

flaps.


Figure 6 Interior exposure of the sulcus pocket with spatula inmicrolaryngoscopy

Figure 7 Sulcus striae major: endoscopic approach

Table 2 Pontes et al. [19]classification of vocal sulcus and similar classifications

Author

Classification

Occult Striae minor Striae major Sulcus pocket

Bouchayer et al. [6] Vergeture Vergeture Sulcus vocalisNakayama et al. [22] Type IIa Type I Type IIbFord et al. [11] Type I Type II Type II Type IIIPerouse and Coulombeau[23] Vergeture first, second and third degree Open cyst



(5) Secondary flaps procedure (Figs 1013): a progress-

ive and alternate approach has to be applied in order

to avoid retraction and loss of control of surgical site.

Usually three to five small counter-incisions have to

be done to obtain three to four mucosal flaps. The

inferior margin of the sulcus has to be surpassed in

order to interrupt the tension line.

(6) Size of secondary flaps (Fig. 14): the surgeon must

be cautious in order to produce the flaps with

different depth to avoid reestablishing the tensional

scar line.(7) Hemostasis (Fig. 15): Hemostasis is generally easily

controlled with adrenalin-embedded cotton; radio-

frequency should be avoided, when possible. No

sutures are necessary.

(8) Positioning of secondary flaps: the slicing movement

will bring about the flaps into an adequate position.

No manipulation is done.

(9) Bilateral approach (Fig. 16): both sides need to be

approached at the same surgical timing; even

though there may be asymmetrical impairment.

This procedure will favor vocal rehabilitation. In

three cases of our series where the bilateral approach

was not respected, results were highly limited.(10) Postsurgical complication: synechiae and granulo-

mas are rarely seen; synechiae are usually soft and


Figure 10 Secondary flaps procedure: first incision

Figure 11 Secondary flaps procedure: four smallcounter-incisions

Figure 9 Main flap procedure

Figure 8 Longitudinal incision at the left vocal fold



can be easily cut without recurrence; small granu-

lomas do not need to be removed.

(11) Postsurgical care: prophylactic antimicrobials and

antireflux drugs should be prescribed; a 2-day com-

plete vocal rest followed by 10-day partial rest regi-

men is administered; vocal rehabilitation starts in

the second week after surgery.

(12) Presurgery and postsurgery: laryngoscopical images

(Fig. 17).

A variant of this technique, the inner vocal ligament

section [35,36], may be used when the glottic chink is

mild or moderate; the result of this procedure can be

optimized with fat injection.

Rehabilitation concerns: from preoperativeassessment to short-term and long-termresults

Two important complaints have to be considered at

preoperative evaluation: the overall degree of vocal

quality deviation and the amount of effort to phonate.

Preoperative voice assessment and a careful counseling

session contribute to patient adherence with surgery and

long-term postoperative rehabilitation.

The sulcus vocalis patient, with an intense degree of

vocal deviation, usually deals with a long-term dysphonia,

which includes frustration and unsatisfactory coping


Figure 14 Secondary flaps procedure: unilateral final view

Figure 15 Hemostasis: adrenalin-embedded cottonFigure 13 Secondary flaps procedure: surpassing inferiormargin

Figure 12 Secondary flaps procedure: progressive approach



strategies. Self-assessment protocols like Voice Handicap

Index(VHI) and Voice-RelatedQualityof Life(V-RQOL)

can reveal very deviated scores[37], with a high disadvan-

tage level [up to 90, extremely high in comparison with

normal voice individuals (3.5)and dysphonic patients], and

a very reduced quality of life regarding the voice impact

[down to 12, very low when compared with healthy voices

(97.1) and dysphonic individuals (71.6), even lower than

scores from laryngectomized patients and severe neuro-

logical cases (Brazilian data)] [3840]. It is interesting to

point out that the number of coping strategies[41]used to

deal with the problem canbe very high, almost40% higher

than the average voice patient, meaning that the patient

tries to cope with it in as many ways as he/she is able to.

Voice after surgery can be even worse than prior to it. The

patient needs to be fully informed and prepared for whathe/she will face. Self-assessment protocols can show even

higherdeviatedscores, even though acoustic, aerodynamic

and stroboscopic data may have improved [37], demanding

a careful long-term follow-up by a multidisciplinary team.

The postoperative vocal evaluation usually reveals the

presence of purely frictional source, without voicing.

Voice rehabilitation after surgery aims to activate glottic

source and to increase tissue pliability.

There is no consensus on the best vocal rehabilitation

protocol for treating the sulcus [17

]. However, in mostof the cases, vocal rehabilitation follows the same general

principles as for vocal fold scar[42]. The recovery process

usually involves both functional and organic issues. A

long-term program of exercises (48 months) is fre-

quently needed in case of severe sulcus submitted to

multiple mucosal slicing surgical technique to release

deep tension lines[34].

The first goal of vocal rehabilitation is to activate

the mucosal vibration in order to avoid supraglottic


Figure 17 Presurgical and postsurgical images

(a and b) Presurgical inspiratory and phonatory images. (c and d) Postsurgical inspiratory and phonatory images.

Figure 16 Both sides approached: final view



involvement and general muscle hyperfunctioning. Two

strategies can be initially used to activate the surgical site:

nasal (m and n) or voiced fricative sounds (v or z). A

clear short-unit production is the goal for the first month

of rehabilitation (usually 10 units, three subsequent

series, 10 times a day). In cases when the ventricular

fold interference persists, inhalation phonation and

yawnsigh techniques can be effective [34]. Fatigue isa frequent complaint at this stage; patients usually report

having to work too hard to phonate. Three to four sessions

a week are needed for the first month until voicing is

achieved. The second goal is to extend voicing to speech

segments, using controlled phonetic environment sylla-

bles, words and phrases. A visual monitoring system, such

as real-time spectrographic trace (GRAM program,

Visualization Software; FonoView Software, CTS Infor-

matica) is of great help in aiding the patient to control

voicing (visualvocal loop). The third goal is to improve

mucosal flexibility by vocal fold elongation and short-

ening exercises (gliding with nasal and voiced fricativesounds). At this moment lip and tongue trills can be

introduced. Semi-occluded vocal tract exercises (reduced

diameter straws or larger glass tubes) can be effective in

dealing with vocal fatigue and promoting vocal endur-

ance. Monitoring fundamental frequency and targeting a

specific low-frequency range may be necessary.

Therapy follows an intensive regimen generally up to

4 months, when once a week or every fortnight dose can

be applied. In some cases, monthly follow-up and

reinforcement sessions are used for a period of a year

after surgery.

ConclusionTheslicing technique surgery forthe severe cases of sulcus

striae major is a complex procedure that requires a skilled

surgeon and a team effort due to a long rehabilitation

program. The treatment goal is to improve functionality

and to reach a stable voice, with reduced effort, which does

not always correlate with a perfectly normal vocal fold.

References and recommended readingPapers of particular interest, published within the annual period of review, have

been highlighted as: of special interest of outstanding interest

Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 578).

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A detailed and comprehensive article on voice surgery.

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Sulcus Mucosal Slicing Technique

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