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Mucosal bridge

Mucosal Bridge

A mucosal bridge lies in the family of disorders such as epidermoid cyst and glottic sulcus. Imagine a cyst that opens in two places, spilling its contents completely. The result is a narrow bridge of mucosa, attached anteriorly and posteriorly.

Not Just a Sulcus—Classic Mucosal Bridges

This 46-year-old woman is an intense, dynamic teacher with children still at home. She describes herself as highly sociable. In fact, on the 7-point talkativeness and loudness scales, she self-describes herself as a “7” and “6”—fitting a classic “vocal overdoer” profile.”

She has been chronically hoarse for several years. The examination showed what was initially expected to be a glottic sulcus. After becoming much more hoarse, she returned 3 years later, at which time a margin swelling was also found on the right vocal cord.

At the time of surgery, an extremely good example of not just one, but two mucosal bridges is found, overlying a deep sulcus. There is usually no benefit from removing a mucosal bridge, and so the surgery was limited to the polypoid lesion.

Postoperatively, even with the mucosal bridge untouched, she found her voice to be much improved.

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polypoid lesion of the right cord

Polypoid lesion + sulcus (1 of 9)

Three years after her initial evaluation, due to increased vibratory injury, there is a polypoid lesion of the right cord (left of photo), at the *. On the left, it appears that there may be a sulcus (see depression at the arrow), and the mucosa on both cords is marbled rather than clear and uniform.
Margin divot on left vocal cord

Margin divot (2 of 9)

Under strobe light, closed phase of vibration, continues to show the polypoid lesion. The left cord (right of photo) appears to have a slight margin divot, again suggesting a sulcus.
Surgical view of polypoid and mucosal bridge on the vocal cords

Surgical view (3 of 9)

In this upside down surgical view, the obvious polypoid swelling on the right draws initial attention. But the more interesting side is on the left. One can already see the larger of the two mucosal bridges, at least at its lateral edge, due to the sulcus at the arrow.
Streching the mucosal bridge with forceps

Streching the mucosal bridge (4 of 9)

The larger of two mucosal bridges is still in place at the tip of the forceps. The smaller mucosal bridge is being stretched medially.
Lifting the mucosal bridge

Lifting the mucosal bridge (5 of 9)

Now both mucosal bridges are being lifted up from the underlying sulcus.
Sulcus beneath mucosal bridges

Sulcus beneath mucosal bridges (6 of 9)

The mucosal bridges are being displaced medially to show the large sulcus beneath both of the bridges.
Polyp removed on right vocal cord

Polyp removed (7 of 9)

The polyp has been removed on the right cord. The mucosal bridges on the left vocal cord have been left alone because their removal does not typically benefit the voice.
Postoperative view of polyp removal

Postoperative view (8 of 9)

Just ten days postoperatively, the patient is aware of major improvement of her voice. The right cord appears already healed and re-mucosalized. The mucosal bridge is seen more clearly than preoperatively.
Vocal cords match under videostroboscopy after polyp removal

Voice restored (9 of 9)

Under strobe light, closed phase of vibration. The match of the folds is much better. Overall, note how subtle the findings of mucosal bridge can be during lab examination, as compared with in the operating room.

Mucosal Bridges from Severe Vocal Overuse

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Vibratory injury

Vibratory injury (1 of 4)

Severe vibratory injury in fitness instructor who is dynamic and extremely intense and “vocal” by nature. Click to enlarge this photo to better see tiny dotted lines that outline the mucosal bridge on each side. The bridges is extraordinarily slender on the right (left of photo).
non-mucosalized granulation tissue

Non-mucosalized granulation tissue (2 of 4)

Now viewed under narrow band light, the bridges are a little more easily seen, and they overlie non-mucosalized granulation tissue on the vocal ligament. A single asterisk is on the midpoint of each bridge.
Open phase of vibration

Open phase of vibration (3 of 4)

Under strobe light, open phase of vibration at D4 (293.66Hz).
closed phase

Closed phase (4 of 4)

Closed phase, at approximately the same pitch.

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