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

South African Journal of Communication Disorders ISSN: (Online) 2225-4765, (Print) 0379-8046 Page 1 of 5 Original Research Effect of voice therapy in sulcus vocalis: A single case study Author: R. Rajasudhakar1 Affiliation: 1 Department of SpeechLanguage Sciences, All India Institute of Speech and Hearing (AIISH), India Corresponding author: R. Rajasudhakar, Dates: Received: 23 Nov. 2015 Accepted: 07 Aug. 2016 Published: 30 Nov. 2016 How to cite this article: Rajasudhakar, R. (2016). Effect of voice therapy in sulcus vocalis: A single case study. South African Journal of Communication Disorders 63(1), a146. http://dx.doi. org/10.4102/sajcd.v63i1.146 Copyright: © 2016. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. 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. Introduction Speech is the most frequent and significant way in which humans use language to communicate. Speech contains fluency, articulation and voice as its components. The systems included in the production of voice are phonatory, respiratory and resonatory systems. Pitch, loudness and quality are the three parameters of voice. Any deviance in these parameters from normality results in voice disorders. Abnormal voice is any voice that calls attention to itself, does not meet the occupational or social needs of the speaker, or is inappropriate to the age, gender or situation (Aronson & Bless, 2010). Voice disorders are mainly classified as organic and functional voice disorders. Organic voice disorders could lead to structural changes in the voice production system. Sulcus vocalis is one of the uncommon clinical conditions caused by structural abnormalities in the vocal folds. It is the focal invagination of the epithelium deeply attaching to the vocal ligament (Bouchayer & Cornut, 2000). The lack of tissue causes a divot in the vocal fold which gives the disorder its medical name ‘sulcus’, which means ‘cleft’ or ‘furrow’ (in Latin). Sulcus vocalis is a groove mainly along the edge of superficial lamina propria. In severe cases, the groove can extend up to the intermediate and the deep layer also. There are three types of sulcus vocalis: physiologic sulcus, sulcus vergeture and sulcus vocalis proper (Ford, Inagi, Bless, Khidr & Gilchrist, 1996). Physiologic sulcus (type 1) is a longitudinal depression that extends along the superficial layer of lamina propria without actually moving the vocal ligament. In physiologic sulcus, there is preserved vibratory activity and anatomic layer of lamina propria as reported. Sulcus vergeture (type 2) is a more extensive longitudinal indentation that does not extend into the vocal ligament, involving loss of superficial, intermittent and deep layer of lamina propria. Sulcus vocalis proper (type 3) is a focal pit which extends beyond the vocal ligament into the thyro-arytenoid muscle (Bouchayer & Cornut, 2000). Read online: Scan this QR code with your smart phone or mobile device to read online. Incidence and prevalence About 15 patients (1.07%) were diagnosed with sulcus vocalis among 1400 patients with voice disorders in Denmark (Greison 1984). The prevalence of sulcus vocalis was estimated in excised vocal folds among laryngeal cancer patients in the USA (Nakayama, Ford, Brandenburg & Bless, 1994). http://www.sajcd.org.za Open Access Page 2 of 5 These authors observed 58 cancer patients and reported 28 (48.3%) had sulcus deformities. Bilateral sulcus was found in 7 of 28 (25%) cancer patients and unilateral sulcus was found in 21 of 28 (75%) cancer patients. The authors even compared the presence of sulcus in non-diseased control patients with cancer patients and concluded that sulci were common in cancer group (Nakayama et al., 1994). Aetiology The cause of this disorder is not widely studied and is poorly understood. The three causes for sulcus vocalis that are reported in the literature are congenital, acquired and unknown causes (Postma, Blalock & Koufman, 1998). The congenital cause includes faulty development of the fourth and sixth branchial arches and rupture of the epidermoid cyst and vocal fold scars are characterised by replacement of the normal micro-architecture by disorganised collagen. Acquired causes are associated with vocal abuse, laryngoesophageal reflux, trauma and infections. Signs and symptoms All the measures of voice such as perceptual, aerodynamic, physiological and acoustics of voice are affected in patients with sulcus vocalis. The clinical features of the disorder include reduced phonation time (aerodynamic), altered fundamental frequency (acoustical), dysphonia, breathiness, harshness, hoarseness of voice (perceptual), vocal fatigue, incomplete glottal closure, interrupted mucosal wave transmission and ‘spindle-shaped’ glottis (physiology) (Boon, McFarlane, Von Berly & Zraick, 2010; Hirano, Yoshida, Tanaka & Hibi, 1990). Treatment There are two lines of management: medical (surgical) and non-medical (behavioural modification, counselling and voice therapy) management. Surgical management includes vocal fold medialisation which includes intrafold injection and medialisation surgery. Intrafold injection includes transoral injection with indirect laryngeal mirror, transoral injection with direct laryngoscopy and transcutaneous injection. The medialisation surgery includes surgical augmentation, medial shift of thyroid cartilage and rotation of arytenoid cartilage (Calton & Casper, 1990). However, studies report that the impacts of surgeries in sulcus are unpredictable and the goal is usually to reduce the glottic leakage. It may also be possible that the post-operative voice would be even worse than the preoperative voice (Giovanni, Chanterect & Lagier, 2007). Voi (...truncated)