Ann Otol Rhinal Laryngol99: 1990
SULCUS VOCALIS: FUNCTIONAL ASPECTS MINORU HIRANO, MD SHINZO TANAKA, MD
TETSUJI YOSHIDA, MD SEISHI HIBI, PHD KURUME,
JAPAN
The vocal function of 126 patients with sulcus vocalis was evaluated with the use of a test battery of multidimensional evaluation items. Ofthe 126 patients, 31 had a unilateral sulcus and 95, bilateral lesions. The results were asfollows. 1) The majority ofthepatients had a mild degree ofhoarseness with a breathy quality. 2) An incomplete glottic closure, a small vibratory amplitude, and a small mucosal wave were frequently observed in thestroboscopic examination. 3) The maximum phonation time, fundamental frequency range, and sound pressure level range ofphonation were decreased, whereas theairflow during phonation was increased. 4) The pitch perturbation quotient, amplitude perturbation quotient, and normalized noise energy were increased. 5) Abnormal test results were more frequent and more marked for bilateral lesions than for unilateral lesions. KEY WORDS - dysphonia, sulcus vocalis, vocal function. Recent technical advances in laryngeal examination including fiberoscopy, microscopy, and videostroboscopy have facilitated visualization of minor lesions of the larynx that had been frequently overlooked with the traditional laryngeal mirror examination. Sulcus vocalis is one of those minor lesions that is apt to be missed. It is not a very rare disease':" and it causes various degrees of dysphonia. The most typical clinical manifestations of sulcus vocalis are hoarseness, bowing of the vocal fold edge, a spindle-shaped glottic gap during phonation, and the existence of a furrow along the vocal fold edge. The ventricular folds are frequently overadducted during phonation in an attempt to compensate for the glottic incompetence. The lesion can be unilateral or bilateral.
Head and Neck Surgery, Kurume University Hospital. The lesion was unilateral in 31 patients (23 men and 8 women) and bilateral in 95 (78 men and 17 women). Table 1 shows the distribution of the patients by age, sex, and laterality. The ages ranged from 24 to 79 years (mean, 61 years). The majority of the patients were over 50 years of age. Those patients who had additional laryngeal disorders, including inflammation, polyps, edema, paralysis, and neoplasms, were excluded from the present series. The test battery employed for vocal examinations consisted of perceptual evaluation of hoarseness by means of the GRBAS (grade, rough, breathy, asthenic, strained) scale; video fiberstroboscopy; physiologic examination including measurements of the maximum phonation time (MPT), mean airflow rate during phonation over comfortable duration (MFRc), fundamental frequency (Fu) range and sound pressure level (SPL) range of phonation; and acoustic analyses of tape-recorded voice." Maximum phonation time, MFRc, Fo range, and SPL range were measured by means of the Nagashima PS-77H, an apparatus for simultaneous recordings of the Fo, SPL, airflow, and air volume. As a result, the measurements were conducted while the pa-
Some functional aspects of this disease entity have been reported on the basis of rather small numbers of patients.v'" Since the vocal function is multidimensional, more comprehensive studies have been demanded in order to elucidate all aspects of dysphonia caused by sulcus vocalis. Such information is relevant to improving treatment modalities for the disease. Hirano conducted an extensive investigation on objective clinical evaluation of the human voice in which the vocal function of patients with sulcus vocalis was studied." However, sulcus vocalis was not the primary focus in his study. The purpose of this paper was to investigate the comprehensive features of the voice disorder caused by sulcus vocalis on the basis of analyses of a large number of patients.
TABLE 1. DISTRIBUTION OF 126 PATIENTS WITH SULCUS VOCALIS BY AGE, SEX, AND LATERALITY Men
SUBJECTS AND METHODS
Women
Age (yr)
U
B
U
B
20-29 30-39 40-49 50-59 60-69 70-79
1 2
2 3 6 18 22 27 78
o o o
1 1
1
5 11 3 23
1
2 3
Total Pts 4 6 9
27
The subjects of this study were 126 adult pa40 3 4 tients, 101 men and 25 women with sulcus vocalis, 4 6 40 who underwent a set of vocal examinations from Total 126 8 17 1983 to 1987 at the Department of OtolaryngologyU- unilateral, B- bilateral. From the Department of Otolaryngology-Head and Neck Surgery, Kurume University, Kurume, Japan. Presented atthe meeting of the American Broncho-Esophagological Association, Palm Beach, Florida, May 2-3, 1990. REPRINTS - Minoru Hirano, MD, Dept of Otolaryngology-Head and Neck Surgery, Kurume University, 67 Asahi-machi, Kurume 830, Japan. 679
Downloaded from aor.sagepub.com at CARLETON UNIV on June 12, 2015
Hirano et al, Sulcus Vocalis
680
TABLE 2. RESULTS OF PERCEPTUAL EVALUATION OF HOARSENESS BY MEANS OF GRBAS SCALE GRBAS Scale
Total
U
B
9 16 2 0
19 66 8 1
28 82 10 1
20 6 1 0
55 37 2 0
75 (62%) 43 (36%) 3 ( 2%) 0
10 15 2 0
24 63 6 1
34 78 8 1
25 2 0 0
78 15 1 0
103 (85%) 17 (14%) 1 ( 1%) 0
26 1 0 0
79 14 1 0
105 (87%) 15 (12%) 1 ( 1%) 0
Grade 0 1 2 3
(23%) (68%) ( 8%) ( 1%)
Rough 0 1 2 3
Breathy 0 1 2 3
(28%) (64%) ( 7%) ( 1%)
Asthenic 0 1 2 3
Strained 0 1 2 3
Data were not available in five cases. GRBAS - grade, rough, breathy, asthenic, strained; U - unilateral, B - bilateral, 0 - none, 1 - mild, 2 - moderate, 3 - severe.
tients phonated into a mouthpiece attached to the apparatus. The MPT and the Fo range measured in this way do not differ significantly from those measured without a mouthpiece. However, the SPL range determined in this way is smaller than that measured without a mouthpiece by approximately 10 dB. 8 In the acoustic analyses, pitch perturbation quotient (PPQ) , amplitude perturbation quotient (APQ), normalized noise energy for the frequency band 0 to 4 kHz (NNEa) , and normalized noise energy for the frequency band 1 to 4 kHz (NNE b) were determined for the sustained lei vowel with the technique by Kasuya et al'" and Kikuchi et al. 11 Standard statistical analyses including determination of the mean, standard deviation, and correlation coefficient and the t test were performed. For the values of MPT, MFRc, Fo, PPQ, and APQ, logarithmic transformation was applied. RESULTS
Perceptual Evaluation. Table 2 shows the results of perceptual evaluation of hoarseness. The majority of the patients had a mild grade of hoarseness. The breathy voice quality was frequently noted, the rough quality was occasionally found, and the asthenic quality and strained voice quality were infrequently recognized. Hoarseness was more frequent and more marked for the bilateral lesions than for the unilateral lesions.
TABLE 3. RESULTS OF VIDEO FIBERSTROBOSCOPY
U
B
Symmetry Symmetric Asymmetric
13 14
55 32
Regularity Regular Inconsistent Irregular
23 2 2
75 3 9
Glottic closure Complete Inconsistent Incomplete
15 0 12
27 3 57
Amplitude Great Normal Small
a 11 16
3 26 58
Mucosal wave Normal 9 Small 18 None a Data were not available on 12 patients. U - unilateral, B - bilateral.
21 63 3
Video Fiberstroboscopy. Table 3 presents the results of video fiberstroboscopy. The most frequent abnormal findings were an incomplete glottic closure during vibratory cycles, a small amplitude of vibration, and a small mucosal wave. These results were observed more frequently for the bilateral lesions than for the unilateral lesions. The mucosal wave frequently was not propagated across the sulcus. Physiologic Correlates. Maximum phonation time ranged from 9.7 to 47.0 seconds with a mean of 18.1 seconds for the unilateral lesions, and from 2.5 to 40.0 seconds with a mean of 13.1 seconds for the bilateral lesions. The difference between the two groups was statistically significant (p < .01). Figure lA depicts the histogram of MPT. Maximum phonation time was shorter than 20 seconds (an approximate average for normal adults) in the majority of the cases. It was shorter than 10 seconds (the lower limit for the normal population) in a considerable number of cases of bilateral sulci. The MFRc measured 63 to 306 mLis with a mean of 148 mLis in the cases of unilateral sulcus, and 83 to 476 mLis with a mean of 195 mLis in the cases of bilateral sulci. The difference between the two groups was statistically significant (p
SULCUS VOCALIS: FUNCTIONAL ASPECTS MINORU HIRANO, MD SHINZO TANAKA, MD
TETSUJI YOSHIDA, MD SEISHI HIBI, PHD KURUME,
JAPAN
The vocal function of 126 patients with sulcus vocalis was evaluated with the use of a test battery of multidimensional evaluation items. Ofthe 126 patients, 31 had a unilateral sulcus and 95, bilateral lesions. The results were asfollows. 1) The majority ofthepatients had a mild degree ofhoarseness with a breathy quality. 2) An incomplete glottic closure, a small vibratory amplitude, and a small mucosal wave were frequently observed in thestroboscopic examination. 3) The maximum phonation time, fundamental frequency range, and sound pressure level range ofphonation were decreased, whereas theairflow during phonation was increased. 4) The pitch perturbation quotient, amplitude perturbation quotient, and normalized noise energy were increased. 5) Abnormal test results were more frequent and more marked for bilateral lesions than for unilateral lesions. KEY WORDS - dysphonia, sulcus vocalis, vocal function. Recent technical advances in laryngeal examination including fiberoscopy, microscopy, and videostroboscopy have facilitated visualization of minor lesions of the larynx that had been frequently overlooked with the traditional laryngeal mirror examination. Sulcus vocalis is one of those minor lesions that is apt to be missed. It is not a very rare disease':" and it causes various degrees of dysphonia. The most typical clinical manifestations of sulcus vocalis are hoarseness, bowing of the vocal fold edge, a spindle-shaped glottic gap during phonation, and the existence of a furrow along the vocal fold edge. The ventricular folds are frequently overadducted during phonation in an attempt to compensate for the glottic incompetence. The lesion can be unilateral or bilateral.
Head and Neck Surgery, Kurume University Hospital. The lesion was unilateral in 31 patients (23 men and 8 women) and bilateral in 95 (78 men and 17 women). Table 1 shows the distribution of the patients by age, sex, and laterality. The ages ranged from 24 to 79 years (mean, 61 years). The majority of the patients were over 50 years of age. Those patients who had additional laryngeal disorders, including inflammation, polyps, edema, paralysis, and neoplasms, were excluded from the present series. The test battery employed for vocal examinations consisted of perceptual evaluation of hoarseness by means of the GRBAS (grade, rough, breathy, asthenic, strained) scale; video fiberstroboscopy; physiologic examination including measurements of the maximum phonation time (MPT), mean airflow rate during phonation over comfortable duration (MFRc), fundamental frequency (Fu) range and sound pressure level (SPL) range of phonation; and acoustic analyses of tape-recorded voice." Maximum phonation time, MFRc, Fo range, and SPL range were measured by means of the Nagashima PS-77H, an apparatus for simultaneous recordings of the Fo, SPL, airflow, and air volume. As a result, the measurements were conducted while the pa-
Some functional aspects of this disease entity have been reported on the basis of rather small numbers of patients.v'" Since the vocal function is multidimensional, more comprehensive studies have been demanded in order to elucidate all aspects of dysphonia caused by sulcus vocalis. Such information is relevant to improving treatment modalities for the disease. Hirano conducted an extensive investigation on objective clinical evaluation of the human voice in which the vocal function of patients with sulcus vocalis was studied." However, sulcus vocalis was not the primary focus in his study. The purpose of this paper was to investigate the comprehensive features of the voice disorder caused by sulcus vocalis on the basis of analyses of a large number of patients.
TABLE 1. DISTRIBUTION OF 126 PATIENTS WITH SULCUS VOCALIS BY AGE, SEX, AND LATERALITY Men
SUBJECTS AND METHODS
Women
Age (yr)
U
B
U
B
20-29 30-39 40-49 50-59 60-69 70-79
1 2
2 3 6 18 22 27 78
o o o
1 1
1
5 11 3 23
1
2 3
Total Pts 4 6 9
27
The subjects of this study were 126 adult pa40 3 4 tients, 101 men and 25 women with sulcus vocalis, 4 6 40 who underwent a set of vocal examinations from Total 126 8 17 1983 to 1987 at the Department of OtolaryngologyU- unilateral, B- bilateral. From the Department of Otolaryngology-Head and Neck Surgery, Kurume University, Kurume, Japan. Presented atthe meeting of the American Broncho-Esophagological Association, Palm Beach, Florida, May 2-3, 1990. REPRINTS - Minoru Hirano, MD, Dept of Otolaryngology-Head and Neck Surgery, Kurume University, 67 Asahi-machi, Kurume 830, Japan. 679
Downloaded from aor.sagepub.com at CARLETON UNIV on June 12, 2015
Hirano et al, Sulcus Vocalis
680
TABLE 2. RESULTS OF PERCEPTUAL EVALUATION OF HOARSENESS BY MEANS OF GRBAS SCALE GRBAS Scale
Total
U
B
9 16 2 0
19 66 8 1
28 82 10 1
20 6 1 0
55 37 2 0
75 (62%) 43 (36%) 3 ( 2%) 0
10 15 2 0
24 63 6 1
34 78 8 1
25 2 0 0
78 15 1 0
103 (85%) 17 (14%) 1 ( 1%) 0
26 1 0 0
79 14 1 0
105 (87%) 15 (12%) 1 ( 1%) 0
Grade 0 1 2 3
(23%) (68%) ( 8%) ( 1%)
Rough 0 1 2 3
Breathy 0 1 2 3
(28%) (64%) ( 7%) ( 1%)
Asthenic 0 1 2 3
Strained 0 1 2 3
Data were not available in five cases. GRBAS - grade, rough, breathy, asthenic, strained; U - unilateral, B - bilateral, 0 - none, 1 - mild, 2 - moderate, 3 - severe.
tients phonated into a mouthpiece attached to the apparatus. The MPT and the Fo range measured in this way do not differ significantly from those measured without a mouthpiece. However, the SPL range determined in this way is smaller than that measured without a mouthpiece by approximately 10 dB. 8 In the acoustic analyses, pitch perturbation quotient (PPQ) , amplitude perturbation quotient (APQ), normalized noise energy for the frequency band 0 to 4 kHz (NNEa) , and normalized noise energy for the frequency band 1 to 4 kHz (NNE b) were determined for the sustained lei vowel with the technique by Kasuya et al'" and Kikuchi et al. 11 Standard statistical analyses including determination of the mean, standard deviation, and correlation coefficient and the t test were performed. For the values of MPT, MFRc, Fo, PPQ, and APQ, logarithmic transformation was applied. RESULTS
Perceptual Evaluation. Table 2 shows the results of perceptual evaluation of hoarseness. The majority of the patients had a mild grade of hoarseness. The breathy voice quality was frequently noted, the rough quality was occasionally found, and the asthenic quality and strained voice quality were infrequently recognized. Hoarseness was more frequent and more marked for the bilateral lesions than for the unilateral lesions.
TABLE 3. RESULTS OF VIDEO FIBERSTROBOSCOPY
U
B
Symmetry Symmetric Asymmetric
13 14
55 32
Regularity Regular Inconsistent Irregular
23 2 2
75 3 9
Glottic closure Complete Inconsistent Incomplete
15 0 12
27 3 57
Amplitude Great Normal Small
a 11 16
3 26 58
Mucosal wave Normal 9 Small 18 None a Data were not available on 12 patients. U - unilateral, B - bilateral.
21 63 3
Video Fiberstroboscopy. Table 3 presents the results of video fiberstroboscopy. The most frequent abnormal findings were an incomplete glottic closure during vibratory cycles, a small amplitude of vibration, and a small mucosal wave. These results were observed more frequently for the bilateral lesions than for the unilateral lesions. The mucosal wave frequently was not propagated across the sulcus. Physiologic Correlates. Maximum phonation time ranged from 9.7 to 47.0 seconds with a mean of 18.1 seconds for the unilateral lesions, and from 2.5 to 40.0 seconds with a mean of 13.1 seconds for the bilateral lesions. The difference between the two groups was statistically significant (p < .01). Figure lA depicts the histogram of MPT. Maximum phonation time was shorter than 20 seconds (an approximate average for normal adults) in the majority of the cases. It was shorter than 10 seconds (the lower limit for the normal population) in a considerable number of cases of bilateral sulci. The MFRc measured 63 to 306 mLis with a mean of 148 mLis in the cases of unilateral sulcus, and 83 to 476 mLis with a mean of 195 mLis in the cases of bilateral sulci. The difference between the two groups was statistically significant (p
