Portuguese Version

Year:  2002  Vol. 68   Ed. 1 - (13º)

Artigo Original

Pages: 75 to 79

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The pediculated flap technique to sulcus vocalis repairing

Author(s): Marcos Grellet 1,
Camila Giácomo Carneiro 2,
Lilian Neto Aguiar 3,
Marcelo Oliveira Rosa 4,
José Carlos Pereira 5

Keywords: sulcus vocalis, voice, phonosurgery.

Abstract:
Introduction: the pedicullate flap technique to repair sulcus vocalis allows the appearing of the mucous wave in this region. Sulcus vocalis cause hoarseness, breathing and roughness. Other symptoms can happen during the speech like effort, fatigue and ardor or burning. Aim: To promote the laryngol mucosal wave though a surgical technique. Material and method: Three patients were submitted to the technique by injection of small quantity of dexametazone, the epithelium stratified squamous joint with superficial layer of vocal fold is separated from the ligament vocalis. The pedicullate flap is dissected from the vocal fold mucous. Results: The postoperative evaluation with videoestroboscopy shows in the topography of the sulcus vocalis a regular and uniform surface with mucous wave. The objective and subjective voice evaluation after one year post operative presents normal results. In this period the symptom effort, fatigue, ardor and burning disappeared in case of unilateral sulcus. In both vocal fold sulci, surgery was performed first at one side, and then in the opposite one. Although we have a short follow up of sulcus in the other vocal fold, voice parameter results are good. Conclusion: the technique achieved fairly results provale functional results in all cases.

1 Associate Professor, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery.
2 Resident physician, Hospital das Clínicas, FMRP-USP, area of Otorhinolaryngology
3 Speech and Voice therapist, Supervisor of the Division of Speech and Voice Therapy, HCFMRP-USP
4 Master degree, Department of Electrical Engineering, Engineering School, São Carlos - USP
5 Faculty Professor, Department of Electrical Engineering, Engineering School, São Carlos - USP

Study presented at the 35º Congresso Brasileiro de Otorrinolaringologia and 9º Congresso Ibero-Americano de Otorrinolaringologia, in Natal-RN - 17 - 21 October, 2000.

Article submitted on February 23, 2001. Article accepted on November 06, 2001.

INTRODUCTION

Voice is the main communication means among people. Its importance has led researchers to try to find the causes of dysphonia and its treatment. Advanced technology has enabled understanding of the phonation dynamics and the importance of laryngeal and vocal fold structures. Microphonosurgery and phonotherapy have developed at the same time.

Sulcus vocalis is a fissure that appears parallel to the free margin of the vocal fold. The term "sulcus" has been used since the beginning of this century, when it was seen through indirect laryngoscopy. It consists of an invagination of the epithelium and the superficial layer of the lamina propria of the vocal fold that gets adhered to the vocal ligament. We may find an inflammatory process in the region, according to Ford and Bless (1991)3. The lining of the sulcus consists of stratified squamous epithelium.

Bouchayer has also described a sulcus on the free medial margin of the vocal fold, named Sulcus Vergeture. It consists of the atrophic depression of the mucosa adhered to the vocal ligament. The sulcus vocalis is generally bilateral and subjects who have sulcus present symptoms such as fatigue during speech, burning sensation, sore throat and the voice becomes harsh, hoarse and breathy because of the vocal fold vibration impairment.

The repair of sulcus vocalis is performed with microphonosurgery. Existing surgical techniques try to correct the sulcus vocalis and provide better voice conditioning, according to Pontes and Behlau (1993)9, Ford et al. (1995)4, Woo et al. (1995)4 and Kass et al. (1996)7.

We present our pedicle flap technique of vocal fold using microphonosurgery and trying to preserve the structures of the fold.

The technique enables repair of sulcus vocalis, improving considerably voice quality.

Postoperative phonotherapy contributes to vocal recovery. Voice assessment is performed by perceptive and acoustic computed analysis (Rosa et al. (1997)11, (1998)12, (2000)13), before and after the surgery.

OBJECTIVE

Using our technique of vocal fold pedicle flap we want to restore the mucosa wave in the region and to eliminate the glottic chink, resulting in better vocal quality.

Method

We operated on the patient ASC, a 19-year old man, with bilateral sulcus vocalis and 02 female patients (MHF and FSS), one with unilateral sulcus vocalis on the right vocal fold and another 13-year-old girl with bilateral sulcus vocalis. Patients complained of hoarseness, vocal fatigue, burning sensation and sore throat.

Videostroboscopy with rigid 70o telescope showed uni or bilateral sulcus vocalis, glottic chink and absence of mucosa wave in the region of the sulcus.

Perceptual vocal analysis using maximum phonation time, pitch, voice type and resonance (Behlau and Pontes, 1998)1 and computed acoustic vocal analysis allowed for pre and post-operative assessment (Rosa et al., 1997)11; (1998)12; (2000)13.

The surgical technique was the following: patient in the operating room, submitted to general anesthesia. The surgical position was horizontal dorsal decubitis with the head slightly deflected. To expose the larynx, we used Storz suspension laryngoscope. Under microscopic view, we exposed the vocal folds and identified the sulcus vocalis (Figure 1). A 5ml syringe was connected to a laryngeal injection needle. With this device, we injected 2mm into the sulcus vocalis a small amount of 4mg dexamethasone in order to help detachment of the stratified squamous epithelium and the superficial layer of the vocal fold adhered to the vocal ligament (Figure 2). Next, using a micro knife, we made an incision on the mucosa comprising the epithelium and the superficial layer of the lamina propria, together with the lateral margin of the sulcus in all its anterior-posterior extension (Figure 3). A parallel incision approximately 2mm from it, was made with similar dimensions up to the exposure of the vocal ligament (Figure 4). The 2nd incision was connected to the first one on the posterior extremity through a transversal incision (Figure 5). By dissecting this mucosa flap, we managed to have a pedicle flap (Figure 6), which was introduced under the lining of the sulcus vocalis that had been detached, elevating it and filling the sulcus (Figure 7). We applied biological glue on the pedicle flap.

RESULTS

Postoperative results, confirmed through videostroboscopy with rigid 70o telescope, showed no further sulcus vocalis, presence of mucosa wave in the region of the sulcus and satisfactory closure of vocal folds after the 30th postoperative day.

There was improvement on voice and strain symptoms, fatigue during speech, burning and sore throat in patients that had bilateral sulcus vocalis and were operated on one of the folds. The findings were gathered little time after the surgery.

The patient that had unilateral sulcus vocalis (Figure 8), after an observation period of 2 postoperative years, showed disappearance of the sulcus vocalis (Figure 9) and presence of normal mucosa wave on the region of the sulcus. The symptoms of hoarseness, fatigue during speech, burning and sore throat in the laryngeal region also disappeared.

Auditory perceptive vocal assessment observed a predominance of laryngeal-pharyngeal resonance, high pitch, reduced maximum phonation time and voice type that was hoarse, harsh and breathy, with varying dysphonia severity, from moderate to severe in the 3 assessed patients (Table 1). Postoperatively, after voice therapy, we noticed improvement of vocal quality since severity of dysphonia had decreased, from normal to moderate. There was balance of resonance in two subjects.

Maximum phonation time was appropriate for age and gender in one subject (unilateral sulcus vocalis) and close to normal in the other 2 subjects (vocal fold bilateral sulcus vocalis). The results were due to the fact that the patients with bilateral sulcus vocalis had been followed up for more than one year postoperatively. The surgery performed in the other vocal fold has been postoperatively followed up only for 30 days. The unilateral sulcus vocalis has been postoperatively followed up for 2 years. Vocal stabilization took place on the 3rd month, coming to its optimal approximately 12 months after the surgery. The pitch was appropriate in one subject (unilateral sulcus vocalis) and pitch of the other two cases of bilateral sulcus vocalis was too high (Table 2).

DISCUSSION

The literature reports that sulcus vocalis promotes hardening of the mucosa of the vocal folds, preventing the normal vibration pattern, impairing the expansion of the lining of the vocal fold during phonation and, consequently, forcing the glottic laryngeal region to select inappropriate motor adjusts to a normal vocal production1, 2, 3, 4.

The infusion of a specific volume of liquid substance (we injected dexamethasone on the superficial layer of the lamina propria), detaches the superficial layer and facilitates resection and/or dissection (Kass et al., 1996)7.

The infusion facilitates the visualization and preservation of the superficial layer of the lamina propria, enabling flexibility of the epithelium of the mucosa of the vocal fold, since these structures present more vibration during phonation.

Ford et al. (1995)4 studied the use of bovine collagen in vocal fold pathologies, including sulcus vocalis, atrophy and fibrosis secondary to trauma and cordectomy. They observed adverse immunological response, limiting its use. They started to use autogenic collagen, better tolerated and more stable in the long run. However, the outcomes of this kind of collagen to compensate glottic insufficiency were the same.

Woo et al. (1995)14 used chromed categut 6.0 to repair non-vibration segments of the vocal fold after microsurgery performed to pathologies such as polypoid degeneration, spindle laryngeal polyp, sulcus vocalis, cyst and keratosis. The non-vibration areas were caused by epithelial thickness, glottic chink and contraction.

Pedicle flap was harvested from the posterior region of the sulcus owing to the vascular characteristics of the vocal folds, that is, large blood vessels arranged in various directions on the posterior and lateral regions of the vocal folds, whereas on the border, the vocal folds presented smaller vessels, arranged parallel to the borders, emerging from the anterior and posterior extremities of the membranous portion (Ford and Bless , 1991)3.

Surgical treatment of sulcus vocalis by vocal fold stripping associated with voice therapy presents good anatomic result, better vibration pattern and vocal quality. Pontes and Behlau (1993)9 and Yamagushi and Koike (1990)15 measured the concentration of hemoglobin and oxygen saturation on the human vocal fold with a spectrophotometer and they found that in subjects with normal vocal fold mucosa the values were 40 and 55, respectively, in the sulcus vocalis and the amount of hemoglobin concentration was 6.

Using our technique of pedicle flap, we intended to correct the sulcus vocalis maintaining the normal vascular irrigation in the area.

Itoh et al. (1983)6 found that bilateral sulcus vocalis during phonation present glottic incompetence and also excessive adduction of the ventricular folds.

Sulcus vocalis is normally bilateral, however, sometimes, there are unilateral sulcus. Histologically, it is located on the superficial layer of the lamina propria.

The epithelium may be thickened and the distribution of capillary vessels around the sulcus is reduced. The deformity of the contour of the vocal fold covering layer contributes to the production of abnormal voice (Ford and Bless 1991)3.

During phonosurgery, we should consider preserving the characteristics of the vocal fold tissue, anatomy of the glottic region, vocal folds vibration pattern and production of laryngeal sound. These considerations are essential for laryngeal production, providing normal sound voice and enabling the operated patient to communicate well.

Sulcus vocalis is a pathology difficult to treat. New therapeutic approaches are introduced to improve the phonation function of the larynx. Owing to its low frequency in the general population, we presented the outcomes of sulcus vocalis correction in three subjects.

Videolaryngoscopy, perceptive vocal assessment and computed vocal analysis pre and postoperatively enabled the assessment of results of the new employed surgical technique.

In our study, it was possible to notice that our surgical technique followed by immediate voice therapy resulted in vocal normalization of unilateral sulcus vocalis. There was improvement of vocal quality in cases of bilateral sulcus vocalis but only one of the sulci was operated at a time in each patient.

Patients with bilateral sulcus vocalis have already been followed up for one year when the other fold was operated on many months after. Perceptive vocal assessment after surgical intervention showed better vocal production. Voice normalization occurred in the case of unilateral sulcus vocalis with a two-year postoperative evolution.

As to acoustic parameters of patient MHF, she showed jitter improvement (1,400% improvement) in the vocalization index (100%) and in signal/noise ratio. In the preoperative study of the patient ASC, the standard jitter, shimmer and vocalization index were not within the expected ranges. Postoperatively, all parameters improved and only vocalization index had not reached the normal range yet. Preoperatively, all parameters were abnormal for the patient ASC. After the surgery, only jitter and vocalization index were abnormal.

CONCLUSION

The technique of microphonosurgery with mucosa pedicle flap employed to correct sulcus vocalis showed very favorable results for vocal rehabilitation of the three cases presented. Studies with larger series are required.

REFERENCES

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