声带沟的诊治进展

声带沟可导致不同程度的发声障碍，严重者对患者的生活和心理均可造成很大影响。本病病因、发病机制尚不清楚，科学的组织学分型对疾病的诊治至关重要，治疗的关键是改善声门闭合不全，恢复声带黏膜振动功能，手术是最主要的治疗方式，此外还有药物治疗、嗓音行为治疗等多种选择，但迄今为止疗效均欠佳。随着人们对声带沟的认识及研究不断深入，以及嗓音医学、组织工程技术、分子生物学、再生医学等领域的发展，未来有望对本病获得更加规范和精准的治疗，从而开辟一条全新的治疗途径。     

声带沟的诊断及治疗

目的探讨声带沟的分型及治疗方法。方法29例声带沟患者按有无声嘶及沟的形态分为3型：Ⅰ型：生理型，11例(无声嘶)；Ⅱ型：裂线型，13例；Ⅲ型：局凹型，5例；后两种为病理型声带沟，有声嘶。对有声嘶18例进行了手术及术后嗓音训练治疗，手术方法有：①黏膜下分离自体脂肪注射术(Ⅱ型9例，Ⅲ型2例，其中1例为术式②疗效不佳再手术者)；②黏膜切开挖槽自体脂肪注射术(Ⅱ型4例、Ⅲ型1例)；③声带沟切除术(Ⅲ型4例，包括1例术式①疗效不佳再手术者)。所有患者均随访6个月以上，平均为15．3个月。结果喉镜及嗓音分析发现，13例Ⅱ型患者中10例(其中6例为黏膜下分离自体脂肪注射术，占该术式6／9；4例为黏膜切开挖槽自体脂肪注射术，占该术式4／4)，术后3个月声带沟消失，发音良好，声带振动恢复；另3例单行黏膜下分离自体脂肪注射术者，术后声带沟变浅，仍稍声嘶。5例Ⅲ型患者中3例行声带沟切除术后4～5个月声带沟消失，发音时声门闭合好，声带振动恢复；另2例先单行黏膜下分离自体脂肪注射术或黏膜切开挖槽自体脂肪术者，术后10d～3个月声带沟再现，再次手术后好转。结论对声带沟患者应分型后采用不同治疗方法，黏膜切开挖槽自体脂肪注射术对Ⅱ型治疗效果最好，声带沟切除术对Ⅲ型治疗最合适。     

Patients’ perceptions of vocal problems: results from a survey in the Tokyo area

Laryngoscopy in cases of sulcus vocalis reveals bowed vocal folds, resulting in a spindle-shaped chink with glottal incompetence. The anatomic and functional problems and resulting incomplete glottal closure during phonation lead to the presenting symptoms of breathy hoarseness, decrease in maximum phonation time (MPT), and vocal fatigue. These symptoms, however, have been reported from the physician’s viewpoint, not the patient’s. Furthermore, no standardized guidelines for the treatment of sulcus vocalis have been established. Because the general attitude toward sulcus vocalis appears to have become ‘It is only a vocal problem and does not significantly affect the patient’s well-being,’ knowledge of sulcus vocalis has decreased and knowledge about choices of therapy remain limited. We therefore conducted an epidemiological questionnaire survey on this pathological condition in voice clinics in seven hospitals in the Tokyo area to establish preliminary guidelines for the management of sulcus vocalis, in reference to the opinion of the patients. Here we report the summary of our preliminary study ‘a survey for sulcus vocalis’ and suggest guidelines for the management of such pathological conditions. Although these management guidelines may result in improvement in the symptoms of sulcus vocalis, patients and physicians should be aware that treatment of this condition is difficult and improvement is not guaranteed.     

Fat augmentation for nonparalytic glottic insufficiency

While autogenous fat augmentation for glottic insufficiency has been used before, relatively little information is currently available on the effectiveness of fat injection in patients with nonparalytic glottic insufficiency resulting from problems such as various defects of vocal atrophy or sulcus vocalis. This paper compares retrospectively the efficiency of fat injection after surgery in patients with vocal atrophy (n = 16) and sulcus vocalis (n = 8). The perceptual acoustic and phonatory functions and videolaryngostroboscopic data were evaluated before and after fat augmentation in 24 patients. The mean follow-up time was 19.5 months. Fifteen patients displayed excellent results; 1 showed some improvement; 6 experienced postprocedure failure, and 2 were not available for follow-up analysis. Perceptual rating showed significant improvement in grade, roughness and breathiness (p < 0.05). The videolaryngostroboscopic rating showed significant improvements in vocal fold edge linearity, vocal fold vibration amplitude and mucosal wave excursion (p < 0.05). More improvement in vocal atrophy was observed compared with sulcus vocalis following fat injection procedures. Our research showed that middle defects improved more compared to those in the anterior and posterior area. Fat injection is an effective autogenous implant and may be considered as an option in the treatment of patients with vocal atrophy or sulcus vocalis. Although fat reabsorption was a problem, repeating the procedure could be considered.     

Voice handicap evaluation of patients with pathologic sulcus vocalis

OBJECTIVES: The purpose of this study was to characterize the psychosocial impact of dysphonia on patients with pathologic sulcus vocalis by use of the Voice Handicap Index (VHI). METHODS: The VHI was administered to 15 patients (11 women and 4 men) with pathologic sulcus vocalis. The VHI subscale and total scores were compared with previously published data from individuals with no history of dysphonia and from patients with vocal fold scar. Additional comparisons were performed for patients with unilateral sulcus versus bilateral sulci, type II sulcus versus type III sulcus, and sulcus with concomitant vocal fold scar versus sulcus without concomitant scar. RESULTS: The VHI scores for patients with pathologic sulcus vocalis were significantly greater than those for individuals with no history of dysphonia and for patients with vocal fold scar. In addition, significantly greater VHI scores were observed for patients with sulcus vocalis with concomitant scar versus those with sulcus alone. CONCLUSIONS: These data suggest that pathologic sulcus vocalis can be a severely handicapping condition, particularly in the presence of concomitant scar.     

小儿声带沟的研究

目的：探讨小儿先天性声带沟的临床特征、诊断、治疗方法。方法：对56例声带沟患儿术前行电子喉镜检查,应用声带沟切开整复术治疗,不附加缝合及用组织或其他外物充填。结果：声带沟占同期嗓音障碍患儿的5．09％（56/1100）,5岁以前占80．04％。总有效率96．40％。结论：声带沟在小儿嗓音障碍中不罕见;出生时即有嗓音异常;多呈裂隙型和凹陷型,常有声带表皮样囊肿或息肉共存;声带沟切开整复术不失为一安全、有效、简捷的手术方式。     

Glottal area waveform analysis of benign vocal fold lesions before and after surgery

Glottal area waveform (GAW) is the plot of relative glottal area versus time through 1 representative glottal cycle. It is derived from the quantitative analysis of the videostroboscopic image. A GAW analysis was performed on 24 patients before and after microlaryngeal phonosurgery. Patients with vocal fold polyps, polypoid degeneration, cysts, sulcus vocalis, and Reinke's edema were included. From each GAW, 5 parameters were determined and compared: maximum normalized glottal area, maximum opening rate, maximum closing rate, percent open time at 50% glottal opening, and glottal gap size. Statistically significant differences in postoperative states included an increased maximum glottal area, an increased maximum opening rate, and an increased maximum closing rate. Glottal opening and closing rate are objective measures of vocal fold pliability that have clinical relevance. The GAW may be used to quantitate vocal fold vibratory capability.     

Fat implantation into Reinke's space: a histologic and stroboscopic study in the canine.

The scarred vocal fold is a cause of persistent dysphonia after laryngeal trauma, microsurgery, and tumor resection. The loss of Reinke's space with scar and stiffness is the primary cause. This study explores the technical aspects of endoscopic implantation of fat as an autologous implant for restoring the bulk and pliability of the vocal folds. Fat from the buccal area was harvested and prepared in 6 dogs. A mucosal flap submucosal pocket was prepared by means of microlaryngoscopy instrumentation. The fat implant was placed into the submucosal pocket. The mucosal flap was sutured endoscopically. Six weeks later, the larynx was harvested and mounted, and vocal fold oscillation was studied while driven by a humidified flow source. The vibratory patterns were studied by stroboscopy. Histologic sections of the vocal folds were made in the coronal plane. All 6 specimens had histologic evidence of viable implanted fat and/or fibrous tissue at the implant site. The site of implantation was in the superior aspect of the vocal fold, but contributed to mass in vocal fold bulk. This increase in bulk histologically corresponded to stroboscopic evidence of increased mass. On stroboscopy, the implant side continued to demonstrate good vibratory function. The study shows that fat implantation can be carried out as an endoscopic procedure. Fat implantation may be useful as a surgical procedure for restoration of Reinke's space. It may be applicable in patients with scars, sulcus vocalis, or vocal fold atrophy.     

Sulcus vocalis in laryngeal cancer: A histopathologic study

The incidental finding of sulcus vocalis in surgical specimens of patients with laryngeal cancer prompted this review. Sulcus deformities were histologically identified in 28 (48%) of 58 whole-mount coronal serial-sectioned laryngeal specimens procured from laryngeal cancer patients. The lesions were analyzed, described, and graded. A control group of 20 larynges, obtained from autopsies of patients without known laryngeal pathology, were similarly processed, and whole-mount histologic sections were studied. Four of these specimens (20%) also demonstrated sulcus deformities. In the control group, the shape and location of the sulci were similar, but the lesions were smaller than in the cancer group. The sulcus lesions revealed chronic inflammation of the subepithelial tissues with vascular ingrowth and fibrosis of the superficial lamina propria (Reinke's space); in the cancer group the sulcus was usually on the opposite vocal fold, where irritation from the tumor might be anticipated. Although the etiology of the sulci remains controversial, these findings suggest that irritation and inflammation might play a role in the pathogenesis of sulcus vocalis.     

New operation for sulcus vocalis--laser vaporization of the sulcus with fat injection

Although several treatments for sulcus vocalis have been reported, the condition continues to be known as an extremely intractable vocal disorder even now. We report the good outcome of a new treatment for sulcus vocalis. The operation was performed under intubated general anesthesia. We aspireted abdominal fat using an 18-gauge needle and a 20 = cc disposal syringe first. After collection of the fat, laryngomicrosurgery and laser vaporization of the sulcus bilaterally was performed using a KTP laser. Then, the collected fat was injected into the thyroarytenoid muscle bilaterally (about 1cc on each side). Seven patients underwent this surgery. The voice, as evaluated auditorily, improved in all the cases and the maximum phonation time increased in 6 of the 7 cases. We attribute the vocal improvement to the formation of new free edges of the vocal folds after this surgery.     

Fiberscopic estimation of vocal fold stiffness in vivo using the sucking method

We developed a fiberscopic device for estimating vocal fold stiffness in vivo. A small plastic tube with a hole in the side was connected to the forceps channel of the fiberscope and used as an aspiration tube under constant negative pressure. A basic experiment revealed that the maximum distance at which the vocal fold was sucked to the hole depended on the stiffness of the tissue. A preliminary study was conducted with a normal subject and four patients: one with sulcus vocalis, one with Reinke's edema, and two with carcinoma. The stiffness estimated using this method was 3 to 4 g/cm for the normal vocal fold. The stiffness for carcinoma and sulcus vocalis was significantly greater than that of normal vocal fold tissue. The stiffness of Reinke's edema did not differ markedly from that of normal tissue.     

Sulcus vocalis: a review

Sulcus vocalis is described as a groove at the free edge of the vocal fold. Different types have been described: sulcus type I is superficial and may be considered as moreless physiologic. Sulcus type IIa corresponds to a kind of vergeture along the margin of the vocal fold. Its deepness is variable but sulcus vergeture may involve deeper layers of the lamina propria. Sulcus type IIb or pounch may be considered as an open cyst. Sulcus lead to a complex glottic dysfunction with, in the same time, a glottal leakage responsible for the breathy component of the dysphonia and a stiffness of the free edge responsible for the roughness. Diagnosis may be difficult even with the help of stroboscopy and finally is sometimes done only under general anesthesia. Etiology remains controversial and the authors present arguments for each theory, acquired or congenital. Treatment options include phonosurgery and speech therapy but phonosurgery gives results often disappointing and surgical treatment must be indicated prudently and patient must be intensively informed on what he or she can expect from the treatment that is mainly an increase of the loudness of the voice.     

Combination of fascia transplantation and fat injection into the vocal fold for sulcus vocalis: long-term results

Fat injection and fascia transplantation alone have been used to treat patients with sulcus vocalis. No information is available on the effectiveness of these two procedures used in concert to treat sulcus vocalis. The objectives of this study were to conduct the two procedures together and report the long-term results. This article assesses, retrospectively, the effectiveness of the combination treatment of fascia transplantation and fat injection (FTFI) in patients with sulcus vocalis (n = 22). Perceptual acoustic, phonatory function, and videolaryngostroboscopic data were evaluated before and after FTFI treatment in 18 patients. The mean follow-up time was 16.6 months. Sixteen patients had excellent results, 3 reported improvement, and 3 indicated no change. Phonatory function improved significantly in terms of phonation time, grade, roughness (p < .05), and breathiness (p < .001). The videolaryngostroboscopic rating showed significant improvement in vocal fold vibration amplitude and excursion of the mucosal wave (p < .05). Type 3 sulcus responded better to this treatment than did type 2 (sulcus vergeture). No postoperative complications were noted. The FTFI technique consists of an autogenous implant and delivers positive results. It may be considered as an option for patients with sulcus vocalis. It has been demonstrated to achieve excellent results in a majority of patients and to deliver a better prognosis than fat injection alone. Although resorption of fat and fascia is associated with FTFI, the FTFI procedure may be repeated multiple times.     

A new surgical technique combining autologous intracordal transplantation of fat and fascia for sulcus vocalis]

We developed a new surgical technique combining autologous intracordal transplantation of fat and fascia for sulcus vocalis. Fat tissue from the abdominal wall and fascia from the postauricular region were obtained and an incision was made on the lateral portion of the vocal cord and a small pocket prepared in the lamina propria using an elevator. After inserting fat tissue into the pocket, fascia was inserted to cover the fat graft to prevent its escape from the pocket. The surgical wound was then sutured using absorbable sutures. No evidence of postoperative absorption of transplanted fat tissue was seen, and vocal function improved postoperatively. This method proved useful as surgical treatment for sulcus vocalis.     

Anatomical study of minor alterations in neonate vocal folds

IntroductionMinor structural alterations of the vocal fold cover are frequent causes of voice abnormalities. They may be difficult to diagnose, and are expressed in different manners. Cases of intracordal cysts, sulcus vocalis, mucosal bridge, and laryngeal micro-diaphragm form the group of minor structural alterations of the vocal fold cover investigated in the present study. The etiopathogenesis and epidemiology of these alterations are poorly known.ObjectiveTo evaluate the existence and anatomical characterization of minor structural alterations in the vocal folds of newborns.Methods56 larynxes excised from neonates of both genders were studied. They were examined fresh, or defrosted after conservation via freezing, under a microscope at magnifications of 25× and 40×. The vocal folds were inspected and palpated by two examiners, with the aim of finding minor structural alterations similar to those described classically, and other undetermined minor structural alterations. Larynges presenting abnormalities were submitted to histological examination.ResultsSix cases of abnormalities were found in different larynges: one (1.79%) compatible with a sulcus vocalis and five (8.93%) compatible with a laryngeal micro-diaphragm. No cases of cysts or mucosal bridges were found. The observed abnormalities had characteristics similar to those described in other age groups.ConclusionAbnormalities similar to sulcus vocalis or micro-diaphragm may be present at birth.     

自体筋膜移植填充治疗声带沟

目的探讨筋膜移植填充术在声带沟治疗中的价值及预后转归。方法23例双侧声带沟患者全麻显微镜下行声带沟瘢痕松解、筋膜移植填充手术，合并声带肌萎缩者同时行声门旁间隙脂肪注射。患者手术前、后行嗓音声学、气流动力学及频闪喉镜检查。结果4例手术失败者未进行疗效评价。19例术后6—8周患者发音开始改善，术后3个月发音改善明显。术后6个月音质趋于稳定，主、客观声学评价及气流动力学参数较术前改善明显，17例（89．5％）患者音质改善明显，声带结构及黏膜振动接近正常，声门闭合明显改善；2例患者音质改善不明显，声带形态接近正常，声门闭合改善，但黏膜振动不良。声音嘶哑主观评分与术前比较改善明显（P值均〈0．05），总评分2例患者（10．5％）提高2个等级，15例患者（79．0％）提高1个等级，2例患者（10．5％）评级无明显改变。除基频外，嗓音声学参数及最大发音时间与术前比较差异均有统计学意义（P值均〈0．01），8例（42．0％）患者声学参数达到正常范围，17例患者（89．5％）最大发音时间达到正常范围。19例患者随诊均6个月-1年，未发现筋膜吸收，其中5例患者随诊满2年，音质稳定。结论筋膜移植填充声带沟的手术可在一定程度上矫正声带固有层缺陷，改善声门闭合不良，恢复声带振动特性。     

Clinical experience with Gray's minithyrotomy procedure

OBJECTIVES: Endoscopic approaches for submucosal vocal fold surgery may limit the surgeon's ability to release scars or to precisely implant filler material such as fat. In 1999, Gray et al described the "minithyrotomy" approach to this region. Technical aspects of this important new technique, clinical indications, and early results are reviewed. METHODS: We performed a retrospective review and compiled the data of the office records, clinical notes, and videostroboscopic examinations of all of the four authors' patients who underwent this procedure. RESULTS: Twenty-one patients underwent 22 minithyrotomy procedures for vocal fold scarring (6), lateralizing scar following polytetrafluoroethylene removal or trauma (5), scar with radiation fibrosis (2), sulcus vocalis (2), or presbylarynx or bowing (6) - bilaterally in 14 operations and unilaterally in 8. There were 13 male patients and 8 female patients, with a mean age of 58.3 years (range, 22 to 87 years). The mean follow-up was 9.1 months (range, 1 to 46 months). After submucosal vocal fold exploration, autologous fat was implanted in 20 of the 21 patients. Postoperative videostroboscopy demonstrated improved mucosal pliability in 19 cases and improved glottal closure in 20 cases. Most patients noted voice improvement. Complications were minimal. CONCLUSIONS: Gray's minithyrotomy is a highly effective approach for treating vocal fold scar processes, bowing, sulcus vocalis, and, potentially, other conditions.     

Communication disorders associated with motor neuron disease: MND

The aim of the paper was to present voice and speech disorders associated with motor neuron disease-MND. Two cases of MND were described. Communication problems--dysphonia and dysartria were one of their early manifestations. It is supposed that sulcus vocalis, which is the result of the degeneration process of the vocal muscle, is the laryngeal presentation of MND.     

Gender-related differences of hyaluronic acid distribution in the human vocal fold

OBJECTIVE: To quantify the distribution of hyaluronic acid (HA) within the normal human vocal fold and evaluate gender- and age-related differences. STUDY DESIGN: Prospective, cross-sectional study by age and gender groups using cadaveric vocal folds to study hyaluronic acid differences. METHODS: Twenty-five vocal fold halves obtained at autopsy were evaluated from nine adult male (age range, 34-52 y), seven adult female (age range, 21-41 y), four geriatric male (age range, 65-77 y), and five geriatric female (age range 65-82 y) subjects. Midmembranous vocal fold sections were stained for HA using the Muller-Mowry colloidal iron (acid mucopolysaccharide) stain with and without hyaluronidase. Digital imaging software was used to quantify the distribution of HA across the lamina propria at the vocal fold edge from superficial (subepithelial) to deep (vocalis muscle). RESULTS: A significant gender difference (P =.03) was noted in distribution when controlled for age. Combined, male subjects had a relatively constant distribution pattern throughout the depth of lamina propria. Female subjects showed relatively less HA in the first 15% of depth (most superficial) but showed more HA in the deeper 40% to 100% (toward vocalis muscle) than in male subjects. CONCLUSIONS: Important clinical implications may be extrapolated from our findings. First, relatively less HA in the most superficial area implies less protection from vibratory trauma and overuse and may explain in part why more female than male patients have phonotrauma to phonotraumatic lesions. Second, evaluating the distribution of HA in the normal human vocal fold allows more direction in our application of HA as a therapeutic lamina propria substitute in patients with voice disorders.     

Sulcus configurations of vocal folds during phonation

Conclusion: A detailed understanding of clinical and voice characteristics will help to differentiate sulcus configuration and plan rational management strategies for each type. Objectives: To investigate the clinical and voice characteristics of patients with sulcus configuration of vocal folds during phonation. Patients and methods: A total of 146 patients with bilateral sulcus configuration of vocal folds were enrolled in this study. Based on videostroboscopic findings, patients were classified into three groups: physiologic sulcus configuration group (type I), pathologic sulcus configuration group, including sulcus vergeture (type II), and sulcus vocalis (type III). Voice analyses were obtained from a recorded speech sample. Results: Thirty-two patients (21.9%) were type I, 61 (41.8%) were type II, and 53 (36.3%) were type III. Different sulcus configuration groups had significantly different roughness and mean fundamental frequency. Type III was significantly different from type I and type II in grade, breathiness, mean flow rate, subglottic pressure, maximum phonation time, Jitter%, and harmonics to noise ratio. The pathologic sulcus showed distinctive features in electroglottograph waveform.