Glottic Sulcus
A degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal cord. The lips of a glottic sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.
A glottic sulcus may be overlooked unless one is familiar with this entity. To paraphrase eminent French laryngeal microsurgeon Dr. Marc Bouchayer, these lesions are diagnosed much more frequently once you know about them than before. At present, aside from having the patient coexist peacefully with this problem via voice therapy and other measures, surgery is the primary treatment modality.
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. Also see the video for this.
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.
Surgical Removal of Glottic Sulcus
Surgical removal of glottic sulcus (1 of 4)
At beginning of surgery, the cord is infiltrated with lidocaine/epinephrine to provide hydrodissection and to expand the mucosa. Line of the sulcus is seen proceding anteriorly from the point of the needle entry.
Surgical removal of glottic sulcus (2 of 4)
An elliptic incision has been made around the lips of the sulcus.
Surgical removal of glottic sulcus (3 of 4)
Right-curved alligator clip tents the medial mucosal flap. Arrows indicate the fine line that represents the opening into the sulcus. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament.
Surgical removal of glottic sulcus (4 of 4)
After the sulcus pocket is removed, gossamer mucosa is tented medially to show remaining flexibility. The voice is expected to be improved, but normal upper voice capabilities are only sometimes achieved.
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.
Nuances of Endotracheal Tube Injury
This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed. Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).
Maximum glottic opening (1 of 8)
Is it paralysis, as diagnosed elsewhere? At a fairly distant view, the maximum opening between the vocal cords at any phase of breathing appears to be approximately a 4mm glottic opening.
Undersurface mucosa indraws (2 of 8)
When the patient inspires rapidly with tracheotomy tube plugged, the vocal cord undersurface mucosa indraws (grey bands at dotted lines), further narrowing the glottic chink. One sees a faint suggestion of breathing tube injury (divot) at the arrow. Notably, there is a very low pitched rumbling sound heard that does not come from the glottis.
Phonation (3 of 8)
During phonation, the cords approximate fully, and in fact the voice is remarkably normal-sounding and she even has an excellent upper range.
Posterior commissure divot (4 of 8)
At close range while breathing with trach plugged, the posterior commissure divot subtly visible in Photo 2 is confirmed. A divot in the right posterior cord “always” indicates that the tube was taped to the left corner of the mouth. The patient’s mother confirmed that this was so.
Further evidence of scarring (5 of 8)
Angling farther posteriorly, additional evidence of inter-arytenoid and possible joint capsule injury is seen. Faint dotted lines outline this area. The problem is not bilateral vocal cord paralysis but posterior commissure scarring, tethering the arytenoids together.
View into trachea (6 of 8)
Looking now into the subglottis and trachea, there is narrowing only at trach entry site, accentuated functionally because the membranous trachea (MT) moves in and out with respiratory phase.
Vibration of trachea (7 of 8)
When the patient plugs the trach tube and inspires rapidly, the deep rumbling sound is again heard, and comes from vibration of the membranous trachea indrawing (arrows) and vibrating (zigzag line).
Open trachea beyond the tube (8 of 8)
A view past the tip of the trach tube shows no secondary area of tracheal stenosis.
The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.
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Glottic Sulcus: Laryngeal Videostroboscopy
Glottic sulcus is a degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal fold. The lips of the sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.
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