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

European Archives of Oto-Rhino-Laryngology https://doi.org/10.1007/s00405-018-5040-2 LARYNGOLOGY Pathological sulcus vocalis: treatment approaches and voice outcomes in 36 patients Beata Miaśkiewicz1 · Agata Szkiełkowska2,3 · Elżbieta Gos4 · Aleksandra Panasiewicz2 Piotr H. Skarżyński4,5,6 · Elżbieta Włodarczyk2 · Received: 8 January 2018 / Accepted: 14 June 2018 © The Author(s) 2018 Abstract 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. Keywords Sulcus vocalis · Sulcus glottidis · Microlaryngoscopy · Injection laryngoplasty · Hyaluronic acid Introduction * Aleksandra Panasiewicz 1 Otorhinolaryngology Surgery Clinic, Institute of Physiology and Pathology of Hearing, Kajetany, Warsaw, Poland 2 Audiology and Phoniatrics Clinic, Institute of Physiology and Pathology of Hearing, Kajetany, Warsaw, Poland 3 Audiology and Phoniatrics Faculty, Fryderyk Chopin University of Music, Warsaw, Poland 4 World Hearing Center, Institute of Physiology and Pathology of Hearing, Kajetany, Warsaw, Poland 5 Heart Failure and Cardiac Rehabilitation Department, Second Faculty, Medical University of Warsaw, Warsaw, Poland 6 Institute of Sensory Organs, Kajetany, Warsaw, Poland Sulcus vocalis is a laryngeal condition linked to a clinically inhomogeneous defect of the covering epithelium with structural malformation of the vocal fold, ranging from minor invagination to the deep focal pits. The classifications used today were introduced by Bouchayer and Cornut [1], and Ford [2]. The two main types of pathological sulci are vergeture (type 2) and open cyst (type 3). Vergeture refers to an atrophic groove under the free edge of the vocal fold; sulcus 3 manifests as a pocket lined with a thick epithelium which goes as deep as the vocal ligament or muscle [1]. Ford and colleagues [2] extended this classification to account for the variability in clinical appearance and distinguished the physiologic sulcus (type 1) with normal or minimally altered mucosal wave and intact layered structure of the lamina propria. 13 Vol.:(0123456789) European Archives of Oto-Rhino-Laryngology There is a very wide range of incidence of sulcus vocalis ranging from 0.4 to 48% [3–6]. The etiology of sulcus vocalis is still controversial. Bouchayer and colleagues speculated that the origin of sulcus was congenital and a result of the fourth and sixth branchial arch anomalies [1]. There have also been reports of familial occurrence [7]. Nakayama and colleagues found high incidence (48%) of sulcus deformities in pathological examinations for laryngeal cancer, and suggested an acquired origin resulted from local trauma and/or chronic inflammation [8]. A mechanism similar to the development of middle ear cholesteatoma was considered by Lee et al. [9]. The heterogeneity in origin and clinical appearance makes the diagnostics and treatment of sulci a challenge [10–12]. There are many treatment modalities for sulcus, but all of them aim to improve voice quality by diminishing the glottal gap and restoring mucosal wave propagation and the symmetry of vibration [1, 2, 12, 13]. The main goal of this study was to evaluate the results of surgical treatment of patients with pathological sulcus. Materials and methods Thirty-six patients with diagnosis of pathological sulcus, treated surgically between 2011 and 2016, were enrolled in this study. The diagnosis was made by a laryngologist–phoniatrist following laryngovideostroboscopic examination and confirmed or revised during microlaryngoscopy. Based on the final diagnosis, there were 22 subjects with type 2 sulcus (Fig. 1) and 14 with type 3 (Fig. 2). Twelve patients were diagnosed with unilateral sulcus, and 24 patients with bilateral sulci. The group consisted of 23 women and 13 men aged from 22 to 70 years (M = 44.17; SD = 11.95). Women Fig. 1  Bilateral sulcus type 2 (LVS) 13 Fig. 2  Bilateral sulcus type 3 (LVS) were aged from 32 to 70 years (M = 43.91; SD = 10.88), and men were aged from 22 to 67 years (M = 44.62; SD = 14.12). Patients reported hoarseness, diminished voice intensity and range of voice, vocal fatigue, and strained, breathy, or unstable voice. The preoperative patient evaluation included psychosocial, auditory-perceptual, acoustic, and laryngovideostroboscopic (LVS) assessment. All diagnostic tests in 36 patients were repeated at 8–12 months postoperatively, but only 7 patients had the follow-up period longer than 1 year after surgery; thus, the group was too small to do the long-term follow-up analysis. The Voice Handicap Index questionnaire (VHI-30) was used [14] and the scores were obtained from 33 patients. VHI total score, and emotional, physical, and functional subscale scores were calculated. An auditory-perceptual evaluation of patients’ voices was carried out with the use of the GRBAS scale [15] which estimates the grade of hoarseness (G), roughness (R), breathiness (B), asthenia (A), and strain in the voice (S) on a scale from 0 to 3 (0, normal; 1, mild; 2, moderate; 3, severe). Ratings, based on a patient’s sustained phonation and a short speech sample, were made by three experienced phoniatrists and the score averaged. The objective acoustic voice analysis was performed with a Computerized Speech Lab (CSL) 4500 external module from KAY Elemetrics Corporation (Lincoln Park NJ). All voices were recorded with an ECM 800 microphone (Behringer) positioned approximately 15 cm from the mouth, at (...truncated)