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Sulcus mucosal slicing technique

ARTICLE in CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY OCTOBER 2010
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Sulcus mucosal slicing technique

Paulo Pontesa and Mara Behlaub
a
Department of Otorhinolaryngology-Head and Neck
Surgery and bDepartment of Speech Language
Pathology and Audiology, Federal University of Sao
Paulo, Universidade Federal de Sao Paulo (UNIFESP),
and professor at Center of Voice Studies CEV
(Centro Estudos da Voz), Sao Paulo, Brazil

Correspondence to Paulo Pontes, MD, Rua Diogo de

Faria 171, Sao Paulo, SP 04037000, Brazil
Tel: +55 11 5549 2188; fax: +55 11 5549 2188;
e-mail: ppontes@inlar.com.br.
Current Opinion in Otolaryngology & Head and
Neck Surgery 2010, 18:512520

Purpose of review
To present the accurate surgical indication for the slicing mucosal technique, the case
selection, surgical aspects, rehabilitation concerns, and the characteristics of
immediate and long-term outcomes.
Recent findings
The literature is still scarce; few cases are submitted to the slicing mucosa technique
due to its specific indication; an alternative procedure was designed for cases where
mucosal movement is strongly reduced, the inner section of the vocal ligament or
submucosal scar tissue, which can eventually be associated with fat inclusion. Some
selected cases may require thyroplasty type III to optimize functional results.
Summary
Slicing technique is an aggressive powerful resource for the surgical treatment of
severe cases of sulcus striae major, in which mucosal wave is absent and glottic chink is
moderate to severe; voice is intensely deviated immediately postoperation; vocal
rehabilitation is mandatory and an intensive regimen is usually required for the first
2 months; final results can mostly be achieved up to 6 months.
Keywords
dysphonia, slicing technique, sulcus striae, sulcus vocalis
Curr Opin Otolaryngol Head Neck Surg 18:512520
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508

Introduction and historical notes

The sulcus was first described by the Italian anatomist
Giacomini, in 1892 [1], and described repeatedly since
then in very few publications [24]. However, with the
advent of better diagnostic tools and dissemination
of knowledge, its identification has been extended
[59,10,11].
There are no data on the incidence of this alteration. The
literature has been exploring two main causes: a congenital deviation/disorder or as a result of trauma. The
congenital disorder cause was described early in the
literature [2], even with a postulation of faulty genesis
of the fourth and sixth branchial arches [6]; degeneration
of fibroblasts in the macula flavae similar to age-related
degeneration of vocal folds [8]. Four familial cases [12]
and monozygotic twin sisters [13] have been described.
Some authors consider that the cause may be due to a
repetitive trauma [5,14], infection or as a rupture of a
vocal cyst [6,15]; other authors admit more than one cause
[46,16] and even speculate that both causes can be
complementary [17].
Our group considers that sulcus has a congenital cause;
however, it is only one of many anatomical variations that
may occur at the vocal fold level. German authors [2,18],
1068-9508 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

in the first half of the 20th century, have already pointed

out that some of these alterations produced no interference with the vital laryngeal function but could eventually hamper the phonatory function of the larynx.
These were called minor congenital anomalies. However,
due to their frequent occurrence and no impact in several
cases, they cannot be considered anomalies or malformations. Our proposal is that these alterations can be
considered anatomical variations, broadly classified into
four morphological categories: sulcus, cysts, mucosal
bridge and microdiaphragms (Table 1) [19].
Taking into consideration the German proposal, we
updated the term by replacing anomaly or malformation
with structural alterations; actually, minor structural alterations. These differentiated anatomical variations are the
utmost expression of a large possibility of deviations, most
of them without a specific morphological identity and, for
this reason, called undifferentiated alterations. These
variations at lamina propriae level also introduce changes
at the vascular network, which loses the classical parallel or
almost parallel distribution in the free edge of the vocal
fold, with dichotomic small caliber vessels at the mucosa.
The altered vascular trajectory should not be considered as
ectasias, varices or other vascular diseases but simply
vascular dysgenesia due to the congenital anatomical
variation of the vocal fold cover [20].
DOI:10.1097/MOO.0b013e3283402a3b

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Sulcus mucosal slicing technique Pontes and Behlau 513

Table 1 Classification of sulcus according to Pontes et al. [19], considering other minor structural alterations of the larynx
Minor structural alterations
of vocal fold cover

Undifferentiated
Differentiated

Sulcus

Occult
Striae

Epidermoid cysts

Minor
Major

Pocket
Deep
Superficial
Fistulized

Mucosal bridge
Laryngeal microdiaphragm
Vascular dysgenesia

The functional impact of a minor structural change

depends on its morphology and on the individual vocal
profile. There is not a direct and simple correlation
between morphology and functional outcome. Besides
the morphological configuration, axiological factors,
personality aspects (extraversion trait), vocal usage, occupational demands and vocal hygiene habits may trigger
the dysphonia. Vocal deviations, besides vocal fatigue
and effort to phonate, can include high-pitched voice,
instability, roughness, breathiness and strain.

Sulcus striae major is visualized as a mucosal depression

similar to a groove or a furrow due to the relative distance
between its lips, creating a superior and inferior margin,
the latter usually rigid (Figs 3 and 4). The vocal impact is
related to the depth of the sulcus, which produces a
distorted mucosal wave that can even be absent. Voice
is rough, tense, high-pitched and usually disagreeable,
sometimes with a diplophonic component; breathiness
can be severe and even produce phonatory breaks. Contrary to the previously presented variant, the sulcus striae
major rarely produces secondary lesions due to lack of
enough glottic closure.

Sulcus classification
The morphological classification of sulcus adopted by us
is as follows: occult sulcus, sulcus striae (or vergeture) and
sulcus pocket.
Occult sulcus

This alteration is solely identified by laryngostroboscopy

during phonation through observation of the mucosal
wave formation. The impact on spoken voice is minimal
and, if present, restricted to vocal range. Dysphonia can
be triggered when vocal loading is enhanced.
Sulcus striae

The term striae (vergeture) was proposed by Bouchayer

et al. [6] in order to characterize vocal fold depressions
similar to skin marks (wrinkles). However, we propose
two variants, the minor and major ones, according to the
distance between the depression lips.

The treatment of this alteration has to consider its main

functional consequence. For discrete cases, vocal rehabilitation can lead to stabilization; for severe cases
(reduced or absent mucosal wave and moderate to large
glottic chinks), surgery is usually applied.
Sulcus pocket

Previously named open cyst or sulcus vocalis [6], a sulcus

pocket corresponds to a real cavity in the vocal fold, in
which the lips still preserve contact [21] (Figs 5 and 6). Its
presentation is usually like a mucosal bump, similar to a
cyst (a frequent misdiagnosis), as the mucosal opening is
Figure 1 Schematic drawing of a sulcus stria minor

In sulcus striae minor, lips are usually in contact along its

whole surface; the image looks like an incision (Figs 1
and 2). The sulcus striae minor can be unilateral or
bilateral, single or multiple, reduced or extended in
length. Its presence can be better visualized during
inspiratory movement, with open vocal folds and less
light contrast at the sulcus surface. In some cases, it is
identified only during exploratory microlaryngoscopy or
surgery for other lesions. The minor striae can reduce the
mucosal vibration and consequently alter vocal quality;
secondary ipsilateral and contralateral lesions, such as
polyps and edemas, are usually seen.

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514 Laryngology and bronchoesophagology

Figure 2 Sulcus stria minor (arrow), under laryngoscopic vision,
during inspiration

Figure 4 Sulcus stria major (arrow), under laryngoscopic vision,

during inspiration

rarely seen in routine examinations. Its mucosal wave has

a better vibratory pattern than the striae sulcus. Glottic
closure can be complete, irregular or with double chink.
Secondary lesions, such as polyps, contralateral reactions,
leukoplakias and chronic laryngitis are frequently associated. Monochorditis is usually a sign of sulcus pocket
presence at vocal fold level. Voice is usually low-pitched
due to the increase of the vocal fold mass. Dysphonia
degree can vary and be present in a fluctuating fashion;
inflammatory episodes are the main cause of vocal variability. Vocal rehabilitation is suggested to improve mucosal vibration, to reduce secondary lesions and to achieve a
differential diagnosis with vocal fold nodules. Surgery for
sulcus pocket is the deepithelization of the cavity.

cation of Pontes et al. [19]. Ford et al. [11] provided a

categorization of three types of sulcus: type I, named
physiological sulcus, is a depression that does not reach
the vocal ligament; type II is a full-length musculomembranous vocal fold depression, extending down to the
vocal ligament or further; and type III is a deep focal
indentation of the vocal fold that does not involve the
whole length of the focal fold.
The surgery is an anatomical procedure with a functional
goal. Therefore, a morphologically based classification is
beneficial to design and plan the surgery.

Management of sulcus striae

Many authors have classified the sulcus with different
criteria, and therefore there is not a correspondence
among them. Table 2 [22,23] presents these classifications distributed similarly to the anatomical classifi-

Several surgical techniques to treat sulcus striae have

been proposed, with variable results: sulcus resection
[24], vocal fold augumentation volume through endoscopic techniques using collagen [25], fat [26,27,28],

Figure 3 Schematic drawing of a sulcus striae major

Figure 5 Schematic drawing of sulcus pocket

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Sulcus mucosal slicing technique Pontes and Behlau 515

Figure 6 Interior exposure of the sulcus pocket with spatula in
microlaryngoscopy

Figure 7 Sulcus striae major: endoscopic approach

muscle fascia implantation [29], external medialization

via thyroplasty type I [30,31], and laryngoplasty with
tissue transposition [32,33].

tricular face tissue to participate in the sound source.

With this procedure, a triple result can be obtained:
pliability of the mucosa, vibratory tecidual structure
and reduction of glottic chink.

In cases with no mucosal wave and cordal vibration (one

mass regimen), with large glottic chinks, the above-mentioned techniques are insufficient to produce a better
vocal quality and/or provide vocal endurance. Vocal fold
medialization or sulculectomy will not be able to provide
mucosal pliability and may even introduce more mechanical resistance to phonate. Therefore, surgical interventions may have to be aggressive, as the tissue preservation rule may not apply here due to the fact that these
patients do not show a normal configuration of the multilayered mucosal structure. In these cases, our surgery
option is using the slicing technique [34].

Technical challenges of the slicing mucosa

technique
There are many technical challenges of the slicing
mucosa technique, some related to the nature of the
alteration and others to the surgeons skills. The goal
of the surgery is to interrupt the longitudinal tension
produced by the presence of the sulcus, as well as to
promote mucosal vibration by bringing the pliable ven-

The main technical challenges are listed below:

(1) Visibility (Fig. 7): adequate visual surgical condition
to perform endoscopic approach surgery.
(2) Soft tissue identification (Fig. 8): longitudinal
incision at the vocal fold vestibular face away from
the edge, as close as possible to the laryngeal ventricle, including the available soft tissue.
(3) Main flap procedure (Fig. 9): out from the longitudinal incision, a tissue flap inferiorly based has to
be created with a 2-mm depth from the sulcus
inferior margin; the tissue flap has to be thick to
preserve vascular properties and avoid necrosis; in
all cases vocal ligament will be partially or totally
included; in a few cases some portion of the thyroarytenoid muscle will take part of the flap.
(4) Number of secondary flaps: a minimum of four
different length incisions, perpendicular from the
free edge of the main flap (counter-incisions) have to
be created in order to produce at least three small
flaps.

Table 2 Pontes et al. [19] classification of vocal sulcus and similar classifications
Classification
Author

Occult

Striae minor

Striae major

Sulcus pocket

Bouchayer et al. [6]

Nakayama et al. [22]
Ford et al. [11]
Perouse and Coulombeau [23]

Type I

Vergeture
Type IIa
Type II

Vergeture
Type I
Type II
Vergeture first, second and third degree

Sulcus vocalis
Type IIb
Type III
Open cyst

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516 Laryngology and bronchoesophagology

Figure 8 Longitudinal incision at the left vocal fold

(5) Secondary flaps procedure (Figs 1013): a progressive and alternate approach has to be applied in order
to avoid retraction and loss of control of surgical site.
Usually three to five small counter-incisions have to
be done to obtain three to four mucosal flaps. The
inferior margin of the sulcus has to be surpassed in
order to interrupt the tension line.
(6) Size of secondary flaps (Fig. 14): the surgeon must
be cautious in order to produce the flaps with
different depth to avoid reestablishing the tensional
scar line.
(7) Hemostasis (Fig. 15): Hemostasis is generally easily
controlled with adrenalin-embedded cotton; radioFigure 9 Main flap procedure

Figure 10 Secondary flaps procedure: first incision

frequency should be avoided, when possible. No

sutures are necessary.
(8) Positioning of secondary flaps: the slicing movement
will bring about the flaps into an adequate position.
No manipulation is done.
(9) Bilateral approach (Fig. 16): both sides need to be
approached at the same surgical timing; even
though there may be asymmetrical impairment.
This procedure will favor vocal rehabilitation. In
three cases of our series where the bilateral approach
was not respected, results were highly limited.
(10) Postsurgical complication: synechiae and granulomas are rarely seen; synechiae are usually soft and

Figure 11 Secondary flaps procedure: four small

counter-incisions

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Sulcus mucosal slicing technique Pontes and Behlau 517

Figure 12 Secondary flaps procedure: progressive approach

can be easily cut without recurrence; small granulomas do not need to be removed.
(11) Postsurgical care: prophylactic antimicrobials and
antireflux drugs should be prescribed; a 2-day complete vocal rest followed by 10-day partial rest regimen is administered; vocal rehabilitation starts in
the second week after surgery.
(12) Presurgery and postsurgery: laryngoscopical images
(Fig. 17).
A variant of this technique, the inner vocal ligament
section [35,36], may be used when the glottic chink is
mild or moderate; the result of this procedure can be
optimized with fat injection.
Figure 13 Secondary flaps procedure: surpassing inferior
margin

Figure 14 Secondary flaps procedure: unilateral final view

Rehabilitation concerns: from preoperative

assessment to short-term and long-term
results
Two important complaints have to be considered at
preoperative evaluation: the overall degree of vocal
quality deviation and the amount of effort to phonate.
Preoperative voice assessment and a careful counseling
session contribute to patient adherence with surgery and
long-term postoperative rehabilitation.
The sulcus vocalis patient, with an intense degree of
vocal deviation, usually deals with a long-term dysphonia,
which includes frustration and unsatisfactory coping
Figure 15 Hemostasis: adrenalin-embedded cotton

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518 Laryngology and bronchoesophagology

Figure 16 Both sides approached: final view

logical cases (Brazilian data)] [3840]. It is interesting to

point out that the number of coping strategies [41] used to
deal with the problem can be very high, almost 40% higher
than the average voice patient, meaning that the patient
tries to cope with it in as many ways as he/she is able to.
Voice after surgery can be even worse than prior to it. The
patient needs to be fully informed and prepared for what
he/she will face. Self-assessment protocols can show even
higher deviated scores, even though acoustic, aerodynamic
and stroboscopic data may have improved [37], demanding
a careful long-term follow-up by a multidisciplinary team.
The postoperative vocal evaluation usually reveals the
presence of purely frictional source, without voicing.
Voice rehabilitation after surgery aims to activate glottic
source and to increase tissue pliability.

strategies. Self-assessment protocols like Voice Handicap

Index (VHI) and Voice-Related Quality of Life (V-RQOL)
can reveal very deviated scores [37], with a high disadvantage level [up to 90, extremely high in comparison with
normal voice individuals (3.5) and dysphonic patients], and
a very reduced quality of life regarding the voice impact
[down to 12, very low when compared with healthy voices
(97.1) and dysphonic individuals (71.6), even lower than
scores from laryngectomized patients and severe neuro-

There is no consensus on the best vocal rehabilitation

protocol for treating the sulcus [17]. However, in most
of the cases, vocal rehabilitation follows the same general
principles as for vocal fold scar [42]. The recovery process
usually involves both functional and organic issues. A
long-term program of exercises (48 months) is frequently needed in case of severe sulcus submitted to
multiple mucosal slicing surgical technique to release
deep tension lines [34].
The first goal of vocal rehabilitation is to activate
the mucosal vibration in order to avoid supraglottic

Figure 17 Presurgical and postsurgical images

(a and b) Presurgical inspiratory and phonatory images. (c and d) Postsurgical inspiratory and phonatory images.

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Sulcus mucosal slicing technique Pontes and Behlau 519

involvement and general muscle hyperfunctioning. Two

strategies can be initially used to activate the surgical site:
nasal (m and n) or voiced fricative sounds (v or z). A
clear short-unit production is the goal for the first month
of rehabilitation (usually 10 units, three subsequent
series, 10 times a day). In cases when the ventricular
fold interference persists, inhalation phonation and
yawnsigh techniques can be effective [34]. Fatigue is
a frequent complaint at this stage; patients usually report
having to work too hard to phonate. Three to four sessions
a week are needed for the first month until voicing is
achieved. The second goal is to extend voicing to speech
segments, using controlled phonetic environment syllables, words and phrases. A visual monitoring system, such
as real-time spectrographic trace (GRAM program,
Visualization Software; FonoView Software, CTS Informatica) is of great help in aiding the patient to control
voicing (visualvocal loop). The third goal is to improve
mucosal flexibility by vocal fold elongation and shortening exercises (gliding with nasal and voiced fricative
sounds). At this moment lip and tongue trills can be
introduced. Semi-occluded vocal tract exercises (reduced
diameter straws or larger glass tubes) can be effective in
dealing with vocal fatigue and promoting vocal endurance. Monitoring fundamental frequency and targeting a
specific low-frequency range may be necessary.
Therapy follows an intensive regimen generally up to
4 months, when once a week or every fortnight dose can
be applied. In some cases, monthly follow-up and
reinforcement sessions are used for a period of a year
after surgery.

Conclusion
The slicing technique surgery for the severe cases of sulcus
striae major is a complex procedure that requires a skilled
surgeon and a team effort due to a long rehabilitation
program. The treatment goal is to improve functionality
and to reach a stable voice, with reduced effort, which does
not always correlate with a perfectly normal vocal fold.

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