Glottic Sulcus
A glottic sulcus is a degenerative lesion of the vocal fold characterized by a longitudinal “slit,” usually a millimeter or two lateral to the vocal cord margin. The slit can be entered to reveal an epithelial-lined “pocket” in the mucosa.
If all “normal” men’s dress shirts were without a breast pocket, a sulcus would be like a dress shirt with a pocket.
This pocket represents the residual cavity of a previously existing epithelial cyst that has ruptured and spilled all of its contents, leaving a defect in the superficial lamina propria. If the length of the opening is similar to the diameter of the cyst, a true sulcus is formed. If the opening is much smaller than the diameter, then some keratinous debris may be retained, creating an “open cyst,” that may appear as an oval white submucosal mass oriented along the same axis as the cord margin.
On laryngeal stroboscopy, especially performed with the highest possible magnification, the margins (“lips”) of a glottic sulcus may be faintly visible. In some cases, the “slit” is not directly apparent, and the diagnosis is suggested instead by marbling of the cord, or abnormal vibratory characteristics, such as reduced mucosal wave or phase asymmetry.
Glottic sulci are frequently underdiagnosed unless the examiner is familiar with this entity. As noted by the eminent French laryngeal microsurgeon Marc Bouchayer, these lesions are identified far more often once clinicians are aware of their existence.
Treatment
At present, treatments are limited. Typically it is best to begin with voice therapy and compensatory vocal strategies especially since patients with this condition are almost all major vocal overdoers, and this is a manifestation of vocal cord vibratory injury. Some patients will decide to coexist with the condition and via “spending less vocal money” at least accomplish a more consistent voice.
Surgical intervention is a second option, particularly if the mucosa is quite thick, with margin convexity. It is possible to improve the voice dramatically, but not guaranteed. If the vocal cord mucosa is thin and the margin is straight or even bowed, a good result from surgery is harder to achieve. With marked bowing and a large glottal gap, medialization via injection or implant placement is occasionally quite helpful, as in this series below.
Surgical Removal of Glottic Sulcus
Initial infiltration (1 of 7)
At beginning of surgery, the cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa. The line of the sulcus is seen proceeding anteriorly (towards the top of the photo) from the point of the needle entry, indicated by the arrows.
The incisions (2 of 7)
The margins of the sulcus will be incised at the faint dotted lines.
Surgical removal of glottic sulcus (3 of 7)
An elliptic incision has been made around the lips of the sulcus.
The buried pocket is being removed (4 of 7)
A right-curved alligator forceps tents the mucosal flap medially. Arrows indicate the fine line that represents the opening into the sulcus. The dotted line circles the entirety of the sac that is being removed. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament.
Surgery completed (5 of 7)
After the sulcus pocket has been removed, gossamer mucosa is tented medially to show its flexibility and stretchability. The voice is expected to be improved, but normal upper voice capabilities are often but not always fully restored.
Sulcus Before Surgery (6 of 7)
In this initial examination, unfortunately defocused, a sulcus is strongly suspected. The oval outlines the lateral and medial lips. The arrow denotes the entrance to the “pocket.” The margin of the cord as a whole is convex, suggesting enough mucosa will remain to cover the cord after removing the sulcus. It appears there may be a sulcus of the left cord (right of photo) as well, but the rest of this post will emphasize the larger sulcus of the right cord (left of photo).
Sulcus after surgery (7 of 7)
Soon after surgery, with the view inverted from the surgical, so that the operated right cord is again on the left. The line indicates what is essentially the incision line, not the entrance to a pocket. Note residual bruising and that the margin of the cord is now straight. Voice is already improved.
Glottic Sulcus, Before and After Surgery
Glottic sulcus, before surgery (1 of 3)
Glottic sulcus, normal light, showing retained material/ granulation emerging from within the sulcus. There is a partial ring of capillaries around the sulcus on the right (left of photo), but no significant vessels within the sulcus (also see next photo).
Glottic sulcus, before surgery (2 of 3)
Same patient. Narrow-band illumination shows the vascular markings more clearly.
Glottic sulcus, after surgery (3 of 3)
Same patient, after surgery. Note microvasculature where it was not present prior to operation; especially noticeable on the right side (left of photo). There is now a continuous layer of mucosa.
Congenital Glottic Sulcus and Bowing, Before and After Injection
Glottic sulcus (1 of 10)
This young patient has a husky, air-wasting voice quality. View of the vocal cords, in breathing position. An abnormality can be seen, especially on the right cord (left of photo, at arrows).
Glottic sulcus (2 of 10)
Under strobe lighting, during phonation, open phase of vibration, at a normal speech frequency (pitch), showing an unusually large amplitude of vibration.
Glottic sulcus (3 of 10)
Closed phase of vibration, but not quite closing completely.
Glottic sulcus (4 of 10)
Closer view, during inspiratory phonation, reveals very clearly that this patient has sulci on both cords, with the open pocket especially visible on the right cord (left of photo).
Sulcus with bowing, just prior to injection (5 of 10)
At the prephonatory instant, under standard light. In addition to a sulcus, this patient has congenital bowing.
Sulcus with bowing, just prior to injection (6 of 10)
Phonation, under standard light, at the pitch E-flat 4 (~311 Hz). Notice in particular the generous width of the zone of vibratory blurring, which correlates with the flaccid, large-amplitude vibration seen in photo 2’s strobe view.
Voice gel injection (7 of 10)
The left vocal cord (right of photo) is now being injected with voice gel. The injection is centered so that the undersurface, free margin, and ventricle all show evidence of bulging.
Voice gel injection (8 of 10)
The other vocal cord is now being injected.
After the injection (9 of 10)
After voice gel injection is completed. At the prephonatory instant. Notice the reduced gap between the vocal cords (compare with photo 5).
After the injection (10 of 10)
During phonation, under standard light, again at E-flat 4 (~311 Hz). The width of vibratory blurring is reduced (compare with photo 6), consistent with reduced amplitude of vibration and reduced air-wasting.
Glottic Sulcus
Glottic sulcus, open (1 of 2)
Same patient, while instrument holds one lip of the sulcus, splaying it open to reveal the empty “pocket” (OR).
Glottic sulcus, closed (2 of 2)
Faint line of glottic sulcus at arrow. Essentially the result of a cyst that has completely emptied of its contents (OR).
Example 2
Glottic sulcus (1 of 2)
Bilateral sulci, more subtle; opening closer to the free margin.
Glottic sulcus (2 of 2)
Same patient. Note the tiny opening of the sulcus right at the margin of the left vocal cord.
Example 3
Glottic sulcus (1 of 2)
Mucosal bridge / glottic sulcus.
Glottic sulcus (2 of 2)
Same patient, showing sulci (arrows) under strobe light.
Example 4
Glottic sulcus (1 of 2)
Note that the “lips” of the glottic sulcus are open; compare to image #2.
Glottic sulcus (2 of 2)
Note that the “lips” of the glottic sulcus are closed; compare to image #1. Also see the video for this.
Example 5
Glottic sulcus (1 of 1)
Shallow sulcus, left vocal cord (right of image), at the free margin.
Glottic Sulcus and Glottic Furrow
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.
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).
Glottic sulcus and glottic furrow (3 of 4)
Same patient. Compare with photo 4 to observe the vibratory appearance of the sulcus and furrow.
Glottic sulcus and glottic furrow (4 of 4)
Same patient. Compare with photo 3 to observe the vibratory appearance of the sulcus and furrow.
Glottic Sulcus Operation
Glottic sulcus operation (1 of 7)
Preoperative exam image, the glottic sulcus is indicated by arrows. (In the remaining photos the view of the larynx is reversed, so the affected area will be on the opposite side of the photo).
Glottic sulcus operation (2 of 7)
Initial operative view showing inflammation, capillary prominence, and margin swelling of the right vocal cord. The sulcus is indicated by arrows, but can be seen much more easily in the next photo.
Glottic sulcus operation (3 of 7)
Rolling the cord laterally with an instrument causes the sulcus to gape open.
Glottic sulcus operation (4 of 7)
A needle is inserted lateral to the still-gaping sulcus to infiltrate for both vasoconstriction and hydrodissection.
Glottic sulcus operation (5 of 7)
The epithelial-lined “pocket” is nearly dissected free from the interior of the cord.
Glottic sulcus operation (6 of 7)
The medial and lateral mucosal flaps are retracted to show the deep layer from which the epithelial-lined pocket was dissected.
Glottic sulcus operation (7 of 7)
At completion of surgery, there is no loss of surface mucosa, and only an incision line.
Open Cyst or Sulcus?
Hoarse voice (1 of 4)
This music teacher has been hoarse for several years. Look for the nuances besides the vascularity and hyperemia, right cord (left of photo) greater than left (right of photo). The next photo makes the findings more obvious.
Open Cyst Definition (2 of 4)
Under narrow band light, note the “pearl” of keratin emerging from the faintly grey sulcus outlined by the tiny dotted lines. When a lot of keratin is retained, we call this an open cyst; when little or none, just a sulcus. Dotted line on the left vocal cord (right of photo) indicates the middle of the sulcus on that side.
Closed phase (3 of 4)
Closed phase of vibration under strobe light at A4 (440 Hz). The right sided sulcus is concealed, but the left side is more visible. The white line (superimposed dots) represents the lateral lip of the sulcus.
Open phase (4 of 4)
Open phase of vibration at the same pitch shows medial and lateral lips with a linear depression between them.
Sulcus and Segmental Vibration
Glottic sulci (1 of 4)
Closed phase of vibration, strobe light, at G3 (196 Hz) in a young high school teacher/ coach who is also extremely extroverted. Faint dotted lines guide the eye to see the lateral lip of her glottic sulci.
Open phase (2 of 4)
Open phase of vibration at the same pitch, showing full-length oscillation.
Closed phase (3 of 4)
Closed phase of vibration at E-flat 5 (622 Hz). Arrows indicate closure of the short oscillating segment.
Segmental vibration (4 of 4)
Open phase of vibration also at E-flat 5, Only the tiny segment opens significantly. As expected the patient’s voice has the typical segmental “tin whistle” quality.
Open Cyst and Sulcus; Normal and Segmental Vibration
Margin swelling (1 of 6)
Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.
Narrow band light (2 of 6)
Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.
Open phase, strobe light (3 of 6)
Under strobe light, open phase of vibration at A3 (220 Hz). The full length of the cords participate in vibration.
Closed phase, same pitch (4 of 6)
At the same pitch, the closed phase again includes the full length of the cords.
Segmental vibration (5 of 6)
At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.
Closed phase (6 of 6)
The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.
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.
Closed phase (2 of 4)
Under strobe light at B-flat 2 (117 Hz), this is the “closed” phase of vibration, perhaps better defined in this instance as the “most closed” phase.
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.
Mottled Vocal Cord Mucosa May Hide Glottic Sulci
Vocal cord swelling and mucosa (1 of 4)
This young “dramatic” soprano is also a bona fide vocal overdoer. Her vocal capabilities have been diminishing for over two years. In this medium-range view, note the rounded swelling of the right cord (left of photo), but more significantly as we shall see, the increased vascularity and mottled appearance of the mucosa.
Same view under strobe light (2 of 4)
Under strobe light, at open phase of vibration at C#5 (523 Hz), we see a projecting, polypoid swelling of the right vocal cord, but not yet the more difficult problem.
Closed phase (3 of 4)
Closed phase of vibration, at the same pitch of C#5 shows the mismatch of the vocal cord margins. Is this the entire explanation for this patient’s hoarseness? Read on.
Glottic sulcus is visible (4 of 4)
At close range and high magnification, the open mouth of a right-sided glottis sulcus is seen. This side can be operated safely due to the excess, thick mucosa and would be expected to improve the margin match. On the left (right of photo), a sulcus is also seen, but the thinner mucosa makes successful surgery on the left more challenging.
A Case That Clearly Shows the Relationship Between Cyst & Sulcus
White Lesion on Right Vocal Cord (1 of 6)
This young man is known as vocally exuberant. For some years, he has used his voice socially to the point of hoarseness countless times, including at heavy metal rock concerts. In the past year or so, his hoarseness never went away. In this distant view, a white lesion is seen on his right vocal cord (left of photo).
White Lesion Under Strobe Light (2 of 6)
Under strobe light and with higher magnification, the open phase of vibration shows this lesion as a white nubbin protruding from a fossa.
White Lesion Under Strobe Light (3 of 6)
The closed phase of vibration shows more clearly the depression from which the lesion is protruding.
White Lesion Removed (4 of 6)
After surgical removal and healing, voice is improved though not fully restored. The lesion was granulation and keratosis. It was plucked from the depression without deepening the pre-existing “divot.”
Vocal Cords (5 of 6)
At the open phase of vibration, showing the trough from which the lesion was removed. There is a smaller depression on the left also consistent with vibratory trauma.
Vocal Cords without Lesion (6 of 6)
The closed phase of vibration. Compare with photo 3.
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