Glottic Furrow

Glottic furrow is a disorder in which a furrow or groove is seen on the vocal cord, running parallel to, and at or just below, the cord’s free margin. It normally represents a defect in the underlying vocal ligament. Often, the deepest part of the furrow is lined with epithelium that is attached directly to thinned vocal ligament. Pseudobowing (due to mucosal and ligament abnormality more than atrophic muscle) is also a common feature.

Can Glottic Furrows Be Acquired?

Normally, we think of “overdoer” disorders as being the following:

vocal nodules
vocal polyps
vocal cord swelling (temporary)
vocal cord hemorrhage (bruising that is also often temporary)
submucosal fibrosis
capillary ectasia
epidermoid cyst
glottic sulcus
mucosal bridge.

In contrast, we tend to think of glottic furrow as “congenital” or “familial.” However, there appears to be a subset in whom glottic furrow may be acquired through extreme and prolonged voice use. Clinically, patients with this tend to present when the furrow is established and so we do not have the opportunity to observe it becoming acquired over time.

In patients with acquired sulci of overuse, this author’s speculation is that extreme voice use “flays away.” Regeneration may be primarily of epithelium and not submucosa, with thin-layer remucosalization directly onto the vocal ligament. It is even conceivable that the vocal ligament is damaged.

The result can include pseudobowing, a thinner vocal quality, chronic huskiness, and reduction of vocal capabilities. In the case of this longstanding heavy metal singer, there is also a lot of capillary damage.

Management at this stage, at its most basic is proper voice care (hydration, etc.) a degree of voice conservation intersecting with appropriate conditioning (not too much and not too little voice use) and adapting to remaining vocal capabilities—refusing to give up any more voice than is already lost.

Beyond conservative care, implant material may be considered. While this would not restore normal mucosa-ligament interaction (the vibratory “cover”), it could improve glottic closure and reduce air-wastage. The following set of images are taken during stroboscopy.

Surface mucosa may have been repetitively “flayed away” and regenerated at intervals during heavy metal screaming or tour conditions. — At E-flat 3 (155 Hz), open phase of vibration (1 of 4)

Vibratory amplitude is very large. That is, the lateral excursion of each cord extends far from the midline, consistent with flaccidity. A deep furrow (dotted line at its greatest depth) is especially evident on the right cord (left of image). Note as well the many capillary abnormalities. Of particular interest is medial to lateral capillary orientation (arrow), often seen when mucosa regenerates. This finding supports the concept that the surface mucosa may have been repetitively “flayed away” and regenerated at intervals during heavy metal screaming or tour conditions.

Also at E-flat 3, “closed phase.” (2 of 4)

The glottis does not achieve complete closure during closed phase.

lengthening of the vocal cord reduces lateral excursion — Falsetto, open phase (3 of 4)

In falsetto, the lengthening of the cord (analogous to stretching a rubber band to elevate the pitch created when twanged) reduces lateral excursion as seen here. The dilated “feeder capillaries” are even more striking at this closer view.

anterior mucosa approximates more closely than the stiffer, nonvibratile mid-cord mucosa — Falsetto, “closed” phase (4 of 4)

Glottic closure is incomplete. The anterior mucosa (arrows) approximates more closely than the stiffer, nonvibratile mid-cord mucosa. The right-sided furrow is better visualized in this image.

Key Words: Furrow, glottic furrow, heavy metal, vocal overdoer, vocal overuse, hoarseness, capillary ectasia

A Glottic Furrow Is Very Different from A Glottic Sulcus!

This middle-aged man presents with concern about a voice that loses strength over the course of the day, and also has a thin quality. He attributes the change to a prior stroke that required prolonged hospitalization (without intubation). He also carries a history of chronic central nervous system injury resembling multiple sclerosis.

Although naturally talkative, he has lived relatively quietly during his extended recovery period.

On retrospective review, he reports that in childhood and early adulthood his voice was strong but did have a “fuzzy,” soft-edged quality.

Laryngeal findings suggest that the primary issue is not stroke-related paresis, but rather: glottic furrows with superimposed voice conditioning (disuse atrophy).

The furrows appear as broad depressions of the vocal folds, rather than a “slit” leading into a pocket. These furrows likely created incomplete glottic closure throughout life, accounting for the long-standing breathy/fuzzy quality.

Thus, the current dysphonia is best explained by the combination of: longstanding furrows with (equally importantly) superimposed voice disuse and deconditioning.

Bilateral furrow (1 of 7)

In this distant view, very obvious furrows are seen. These are not glottic sulci, which appear as more of a “slit” leading into a pocket, which is the residual lining of a ruptured cyst. Instead, a furrow can appear as a broad depression overlying thinning of the vocal ligament and loss of the Reinke’s space (superficial layer of the lamina propria), so that epithelium is adherent directly to the thinned vocal ligament.

Outlines of furrow — Closer view (2 of 7)

At a more revealing magnification, the findings of photo 1 are even more obvious. Note that it is as though each furrow has an inferior and superior lip or margin at dotted lines.

Open phase (3 of 7)

The open phase of vibration under strobe light, but beginning to close. The inferior lip of the furrow is approaching contact.

Near closed phase (4 of 7)

Both furrows are still seen above / lateral to their now nearly-touching inferior lips.

Closed phase (5 of 7)

Now the superior lip of the furrows are in contact, obscuring the furrows inferior to them.

Glottic sulcus open — Sulcus open (7 of 7)

An instrument is holding the pocket open. Again, this is very different from a glottic furrow.

Glottic Furrow vs. Glottic Sulcus

A furrow is to be distinguished from a sulcus, which is more a defect within the mucosal layer only, and is thought to represent the empty sac of what was formerly a cyst. A furrow is typically shallow, and its lips are apart; a sulcus is usually deeper, and its lips are in contact and therefore harder to see. A furrow normally adheres to the vocal ligament, and the apex or deep surface of a sulcus often does as well. However, in the case of a sulcus, the vocal ligament itself is normal.

Also, in the case of a furrow, the mucosal layer—often only an epithelial layer, in fact—will tend to adhere more broadly to the ligament, due to loss of the Reinke’s space layer of the mucosa.

Glottic sulcus and glottic furrow (1 of 4)

This patient has a glottic sulcus on the left vocal cord (right of image) and a glottic furrow on the right vocal cord.

inspiratory phonation with glottic sulcus and glottic furrow — Glottic sulcus and glottic furrow (2 of 4)

Same patient, inspiratory (breathing in) phonation. Note how this accentuates the opening of the sulcus on the left vocal cord (right of image).

Example 2

A rough and fuzzy voice (1 of 6)

This middle-aged woman describes a fuzzy and rough voice quality with fading of strength and endurance across a typical day’s use. A part of the explanation is seen here: an obvious furrow of the left vocal cord (arrow, right of photo). Glottic furrows are usually congenital defects involving thinning of the vocal ligament and application of epithelium (mucosa) directly to the ligament with little if any “Reinke’s space” (superficial layer of lamina propria).

Furrow (2 of 6)

Narrow band light makes the furrow more evident.

asymmetrical vibration (3 of 6)

Partially open phase of vibration, seen at F4 (349.23Hz) under strobe light reveals the issue of asymmetrical vibration and phase shifting that often correlates with rough quality.

Closed phase ( 4 of 6)

Closed phase of vibration, with the furrow still very visible.

vibration points amplify (5 of 6)

At lower pitch (approximately G3 (196.0Hz), very large amplitude of vibration points out the flaccidity of the vocal cords, and the furrow at the arrow.

Glottic Furrow

leading edge of non-adherent vocal cord mucosa has slid medially — Glottic furrow (4 of 4)

At this patient’s most closed phase of vibration, under strobe light. Note that the leading edge of non-adherent vocal cord mucosa (again indicated by arrows) has slid medially (compare with photo 3).

Glottic Furrow / Leukoplakia / Acid Reflux

Leukoplakia (2 of 4)

Furrow-like groove best seen on the left vocal cord (arrow). Beneath the arrow is the leukoplakia. Notice loss of fine surface vessels in this area.

Gap between vocal cords during closed phase — Gap during closed phase (4 of 4)

Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

Glottic Furrow, Showing Adherent Furrow Muscoa

bilateral glottic furrows (2 of 4)

Closer view, now showing the bilateral glottic furrows more clearly (indicated by the dotted lines).

medial oscillatory position (3 of 4)

Under strobe light, closed phase of vibration. Focus on the right cord (left of photo), and note that the dotted line shows medial oscillatory position of mobile mucosa. The small elevation indicated by the large dot is a reference for comparison with next photo.

Mucosal Wave (4 of 4)

Open phase of vibration. The mucosal wave is very far lateral on the upper surface of the vocal cord, indicated now by the curved dotted line. The small elevation has barely lateralized, consistent with the adherent stiff mucosa of the furrow itself.

Glottic Furrow—A Thinning of Reinke’s Space

Strobe light (2 of 4)

This view under strobe light shows the right-sided furrow enclosed by tiny dots.

vocal cord margins match well at high pitch — High pitch (3 of 4)

At very high pitch under strobe light, vocal cord margins match well; the cause of this man’s hoarseness is not a typical vibratory injury such as nodules or a polyp.

Thinning of Reinke's space — Thinning of Reinke’s space (4 of 4)

Open phase of vibration, with only the lateral edge of the furrows marked with a dotted line. Part of the stretchy “cushion” of Reinke’s space is lost and with it the mechanical de-coupling of mucosa from vocal ligament beneath.

Double Whammy: Intubation Injury + Glottic Furrows

Intubation injury (3 of 4)

As the vocal cords begin to close, this view (deep into the posterior commissure) shows clearly the divots caused by pressure necrosis outline where the breathing tube sat. Dotted lines show what would be the normal line of posterior vocal cords.

Phonatory position (4 of 4)

Now in closed voice-making position, posterior defect is out of view, but the vocal processes remain visible and come into contact at arrows. This shows that the endotracheal tube injuries are divots only without scarring of the joint capsules (that if present would prohibit contact of the vocal processes at arrows). There is air wasting through the posterior keyhole not visible here, and the bilateral glottic furrows and pseudo-bowing are extremely evident. They cause additional air-wasting, and adherence of mucosa at the depth of the furrows interferes with the mucosa’s vibratory ability.

Furrow Causing Chronically Husky Voice After Years of Extensive and Often Intense Voice Use

Huskiness (1 of 4)

Huskiness in the context of the series title. Subtle “depressions” in the area outlined become more obvious in the following photos.

Pre-phonatory view (2 of 4)

As the vocal cords come slightly towards each other in preparation to make voice, the depressions are a little more evident.

Depressed area (3 of 4)

Here the depressed area is best seen at low pitch.

High pitch (4 of 4)

At high pitch, the depression elongates and becomes shallower.

Glottic Furrow—Not Just Bowing and not Glottic Sulcus

Bowing vocal cords with furrows (1 of 4)

This middle-aged man’s voice has become increasingly husky and weak across many years. In retrospect, it was never a “strong” voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but “furrow” would be the better definition, as seen in the next photo.

Lower pitch reveals furrow (4 of 4)

At lower pitch, the amplitude of vibration is larger and the right cord (left of photo) reveals more clearly that the the linear depression is a wide furrow, not a slit-like sulcus.

Glottic Furrow vs Glottic Sulcus | They Are Not the Same!

Imagine the confusion if the pocket on a dress shirt were called a furrow—or the furrow in a freshly plowed field were called a pocket instead.

This is essentially what happens when the terms furrow and sulcus are used interchangeably to describe vocal cord abnormalities. In fact, these two terms refer to distinctly different findings with important implications for diagnosis and treatment.

In this video, Dr. Bastian explains the difference between a vocal cord furrow and a sulcus, and why using the correct term matters.

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Glottic Furrow

Can Glottic Furrows Be Acquired?

At E-flat 3 (155 Hz), open phase of vibration (1 of 4)

Also at E-flat 3, “closed phase.” (2 of 4)

Falsetto, open phase (3 of 4)

Falsetto, “closed” phase (4 of 4)

A Glottic Furrow Is Very Different from A Glottic Sulcus!

Bilateral furrow (1 of 7)

Closer view (2 of 7)

Open phase (3 of 7)

Near closed phase (4 of 7)

Closed phase (5 of 7)

Sulcus closed (6 of 7)

Sulcus open (7 of 7)

Glottic Furrow vs. Glottic Sulcus

Glottic sulcus and glottic furrow (1 of 4)

Glottic sulcus and glottic furrow (2 of 4)

Glottic sulcus and glottic furrow (3 of 4)

Glottic sulcus and glottic furrow (4 of 4)

Example 2

A rough and fuzzy voice (1 of 6)

Furrow (2 of 6)

asymmetrical vibration (3 of 6)

Closed phase ( 4 of 6)

vibration points amplify (5 of 6)

Furrow (6 of 6)

Glottic Furrow

Glottic furrow (1 of 4)

Glottic furrow (2 of 4)

Glottic furrow (3 of 4)

Glottic furrow (4 of 4)

Glottic Furrow / Leukoplakia / Acid Reflux

Glottic furrow / Leukoplakia / Acid reflux (1 of 4)

Leukoplakia (2 of 4)

Glottic furrows (3 of 4)

Gap during closed phase (4 of 4)

Glottic Furrow, Showing Adherent Furrow Muscoa

Glottic furrow, showing adherent furrow muscoa (1 of 4)

bilateral glottic furrows (2 of 4)

medial oscillatory position (3 of 4)

Mucosal Wave (4 of 4)

Glottic Furrow—A Thinning of Reinke’s Space

Glottic furrow (1 of 4)

Strobe light (2 of 4)

High pitch (3 of 4)

Thinning of Reinke’s space (4 of 4)

Double Whammy: Intubation Injury + Glottic Furrows

Intubation injury + glottic furrows (1 of 4)

Bilateral glottic furrows (2 of 4)

Intubation injury (3 of 4)

Phonatory position (4 of 4)

Furrow Causing Chronically Husky Voice After Years of Extensive and Often Intense Voice Use

Huskiness (1 of 4)

Pre-phonatory view (2 of 4)

Depressed area (3 of 4)

High pitch (4 of 4)

Glottic Furrow—Not Just Bowing and not Glottic Sulcus

Bowing vocal cords with furrows (1 of 4)

Closed phase (2 of 4)

Open phase (3 of 4)

Lower pitch reveals furrow (4 of 4)

Glottic Furrow vs Glottic Sulcus | They Are Not the Same!

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