Sulcus Vocalis: An Underrecognized Cause of Hoarseness in Singers

MANY DIFFICULTIES CAN PREVENT SINGERS from reaching their fullest potential. While certain obstacles are technique related, others are the result of medical pathology impairing function with varying degrees of severity. Symptoms of anatomic problems range from inability to maintain pitch effectively to diminished voice quality rendering singers unable to perform professionally. One survey showed that more than half of young singers reported vocal difficulties including hoarseness, fatigue, decreased range, and breathiness.1 While most singing teachers recognize the need for evaluation by a laryngologist, many conditions escape early detection and diagnosis by traditional methods of vocal fold evaluation. It is important to acknowledge that, although no underlying pathology may be uncovered during an initial visit, more subtle pathology such as sulcus vocalis may be causing singing difficulties otherwise ascribed to lack of discipline or even vocal senescence.Sulcus vocalis refers to a long, thin groove running lengthwise along the vocal folds.2 Sulci extend along the surface layer of the vocal folds, called epithelium, as an invagination toward the underlying vocal ligament. True sulcus vocalis results from scarring of the surface epithelium to the underlying vocal ligament as a result of loss or absence of the loose layer in between, known as the superficial lamina propria.3 Sulci can be divided into three categories, based on microscopic appearance.4 Type 1 sulcus vocalis, known as physiologic sulcus, refers to a shallow groove in the vocal fold that doesn't alter physiologic movement, and, therefore, generally doesn't result in dysphonia. Type 2, also known as sulcus vergeture, is the result of partial loss or thinning of the superficial lamina propria, as opposed to type 3, known as true sulcus vocalis, which represents a true invagination of the surface epithelium down to the vocal ligament. Both types 2 and 3 sulci refer to higher grade, pathologic lesions that may cause dysphonia.The etiology of sulcus vocalis is controversial. Early thought focused on a congenital basis for sulcus, favoring a developmental defect. Sulci also have been suggested to be due to a ruptured epidermoid cyst within the vocal fold. These hypotheses have been supported by findings of sulcus abnormalities and early dysphonia in children, the absence of recurrence after resection (indicating that a continuing source isn't present),5 and familial tendencies.6 Others have argued for acquired causes such as phonotrauma, vascular lesions, and postoperative scarring. Supporting evidence includes a low incidence of dysphonia in childhood, with over two thirds occurring after 40 years,7 and findings of bilaterality and higher rates of sulcus in patients with cancer or inflammatory laryngeal changes.8 The true etiology remains undetermined and may involve any or all of these proposed causes.Dysphonia generally ensues because of vocal fold stiffness leading to improper propagation of the mucosal wave. Additionally, glottic incompetence, or the inability of the vocal folds to close completely, leads to air leakage and decreased vocal efficiency. Patients characteristically present with strained vocal quality (described as harsh or reedy), pain, and/or fatigue. Most patients with symptomatic sulcus present with increased breathiness and/or hoarseness. Also noted are decreased maximum phonation time, range, and sound pressure levels.9 Patients typically find phonation more effortful with increased difficultly being heard over background noise. These symptoms may correlate more with glottic incompetence than with stiffness. Sometimes, an elevation in the pitch of the spoken voice can accompany the disorder, leading some men to complain that they are mistaken for women on the phone.An otolaryngologist specializing in voice, known as a laryngologist, should evaluate voice professionals with complaints suggestive of sulcus vocalis. …