Sulcus Vocalis (Type III): Prevalence and

Strobovideolaryngoscopy Characteristics
*A. Morgan Selleck, Jaime Eaglin Moore, Amy L. Rutt, *Amanda Hu, and *Robert T. Sataloff, *Philadelphia,
Pennsylvania, yRichmond, Virginia and zJacksonville, Florida

Summary: Objectives. The reported prevalence of sulcus vocalis (SV)/type III, a pathologic groove in the vibratory
margin of the vocal fold, varies greatly in the literature. Difficulties in visualizing the defect and a variety of descriptions
have complicated the evaluation of SV. The objective of this study was to determine the prevalence of SV by reviewing
strobovideolaryngoscopy (SVL) examinations in subjects with and without dysphonia.
Study Design. Retrospective chart review.
Methods. Charts and SVL images were reviewed for subjects with and without dysphonia and analyzed using standard statistical techniques.
Results. SVL images were reviewed for 94 nondysphonia subjects and 100 dysphonia subjects. For all subjects, 19.6%
had type I, 2.1% had type II, and 5.7% had type III/SV. Per vocal fold, 14.7% had type I, 1.3% had type II, 3.1% had type
III/SV and 13.1% had scar. The prevalence of SV per subject was not significantly different between the two groups (8%
of dysphonia subjects, 3.2% of nondysphonia subjects). Male gender, decreased amplitude, decreased waveform, and
hypodyamic motion were significantly higher in the dysphonia SV subjects compared with the non-SV subjects. All
other SVL characteristics were not significantly different in subjects with SV compared with non-SV subjects.
Conclusions. We report a prevalence of SV/type III at 3.1% (per vocal fold) and 5.7% (per subject). Higher
frequencies of male gender and waveform abnormalities were seen in the dysphonia SV subjects only. There were
no significant differences in nondysphonia subjects with or without SV.
Key Words: SulcusStrobovideolaryngoscopySulcus vocalis.
INTRODUCTION
A vocal fold sulcus is a groove in the musculomembranous
portion of the vocal fold, and several articles have defined subcategories of this pathology.1,2 Fords commonly used
classification system breaks down sulcus deformity into three
types.3 Type I is a physiological sulcus, whereas types II and
III are pathologic.3,4 Type II, or sulcus vergeture, is a groove
in the vocal fold from atrophy of the superficial layer of the
lamina propria.3,4 Type III, or sulcus vocalis (SV), is a pit in
the vocal fold edge.3,4 There is absence of the superficial
lamina propria with epithelium adherent to the vocal
ligament, and there can be involvement of the vocalis muscle
(Figure 1). Type III sulcus may have the appearance of an
open cyst with thickened epithelium.3,4 Type III sulcus is
considered a true sulcus and is referred to as SV in the
remainder of the article (Figure 1).
Classically, SV is associated with bowing of medial edge of
the vocal fold, increased stiffness, glottic insufficiency, and
compensatory
hyperfunction.4
These
abnormalities
can cause severe dysphonia, but symptoms may vary from
the expected hoarseness to completely normal voice.3,5
Sulcus have been visualized without stroboscopy,3 but
strobovideolaryngoscopy (SVL) provides a more detailed

evaluation of the mucosal wave making it an effective tool

in diagnosis.4,6
The reported prevalence of SV deformities varies greatly.
Rates range from 0% to 9% with the majority of these data coming from cadaver studies.3,5,710 In a group of 1200 postmortem
larynges, Shin7 discovered an incidence of only 0.4%. Another
autopsy study by Ishii et al9 found a sulcus incidence of 2.5% in
200 larynges. A cadaver study by Sunter examined 200 vocal
folds and found a sulcus deformity in 28.5%, with 9% of vocal
folds having SV.5 An autopsy study by Nakayama10 found six
SV in 122 vocal fold (4.9%) examined. Ford et al examined
116 nondysphonia patients using SVL and found nine with sulcus deformities. These patients were considered as having
physiological sulcus (type I sulcus) based on their absence of
symptoms.3
Previous variations in classification and the wide variety of
presentations have made diagnosis and thus the determination
of prevalence difficult. Prior studies have been focused on
evaluation of cadavers. In Ford et als study, SVL was used
to examine select populations. To our knowledge, this study
is the first to determine the prevalence of SV by SVL in patients with both dysphonia and without dysphonia and
describe the SVL characteristics of SV in a diverse patient
population.

Accepted for publication September 11, 2014.

From the *Department of Otolaryngology - Head and Neck Surgery, Drexel University,
College of Medicine, Philadelphia, Pennsylvania; yDepartment of Otolaryngology Head
and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia; and the zDepartment of Otorhinolaryngology, Mayo Clinic, Jacksonville, Florida.
Address correspondence and reprint requests to Robert T. Sataloff, Department of
Otolaryngology Head and Neck Surgery, College of Medicine, Drexel University,
1721 Pine St., Philadelphia, PA 19103. E-mail: rsataloff@phillyent.com
Journal of Voice, Vol. 29, No. 4, pp. 507-511
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.09.015

METHODS
A retrospective chart review was approved by the Institutional Review Board at Drexel University College of Medicine. For the study, 94 nondysphonic and 100 dysphonic
subjects were identified from the senior authors laryngology
practice (R.T.S.) who met the study criteria. Inclusion
criteria included availability of high-quality rigid SVL images for review. Exclusion criteria included history of

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Journal of Voice, Vol. 29, No. 4, 2015

TABLE 1.
Demographic Data of the Dysphonia and Nondysphonia
Groups With Breakdown of the Nondysphonia Group

Demographic Data
Gender (male: female)
Age (mean SD,
range)
Professional voice
users (%)
History of vocal
abuse (%)

Dysphonia
Group
(n 100)

Nondysphonia
Group (n 94)

28: 72
49.2 18.3,
1680
75

44: 50
33.3 12.4,
1473
79.8

96.9

83

Abbreviation: SD, standard deviation.

FIGURE 1. Sulcus vocalis (SV) of the left vocal fold.

laryngeal trauma (excluding vocal abuse), laryngeal surgery,
and poor quality or absence of rigid SVL images. Subjects
were divided into two groups based on the presence or
absence of dysphonia.
Demographic data and history as documented in the chart
were reviewed. Rigid SVL images were reviewed by trained
laryngologists for abnormalities including the presence of a sulcus based on Fords classification system. An absence of the
lamina propria and pit-shaped deformity had to be present to
make a diagnosis of SV (Type III), and SVL were reviewed a
minimum of twice before establishing a consensus diagnosis.
Other structural abnormalities were defined as scar, sulcus vergeture/type II and type I sulcus depending on the characteristics
of the defect. SVL findings recorded included objective
dysphonia, muscle tension dysphonia (MTD), paresis/paralysis,
glottic insufficiency, laryngopharyngeal reflux (LPR), Reinkes
edema and vocal fold masses/lesions. Abnormalities of the
vocal fold amplitude, waveform, and vibration were identified.
Statistical analysis was conducted using Statistical Package
for the Social Sciences, Version 20.0 and Microsoft Excel. Demographic data and SVL information were analyzed using
Fisher exact test and t test for independent samples. Subjects
with scar and sulcus vergeture/type II were excluded from the
non-SV groups during analysis. Analysis was performed per
vocal fold for amplitude and waveform, whereas all other
data points were analyzed based on subject.

RESULTS
The study population consisted of 194 patients: 94 nondysphonia and 100 dysphonia. The demographic data of both groups
are included in Table 1. Of the nondysphonia subjects, 63
were operatic singers presenting for baseline examination and
31 were subjects that had incidental findings on mirror laryngoscopy prompting SVL or had SVL performed for another
study. Of the dysphonia group, all patients were consecutive
new or follow-up patients presenting to the senior authors office over a 6-month period, who met study criteria. The most
common vocal complaints for the dysphonia group are listed
in Table 2. Most subjects in both groups were professional voice

users (81% dysphonia, 74.4% nondysphonia) and had a history

of phonotrauma (96.9% dysphonia, 85.1% nondysphonia).
Gender was the category with the largest difference between
groups, but it was not significant (P NS).
For all subjects, 19.6% had type I, 2.1% had type II, and 5.7%
had type III/SV, and four subjects had two types of sulcus. The
prevalence of SV was not significantly different between the
groups (3.2% nondysphonia, 8% dysphonia). The location of
the SV was bilateral in one patient (9.1%), on the left vocal
fold in six patients (54.5%), and on the right vocal fold in
four patients (36.4%). Per vocal fold, 14.7% had type I, 1.3%
had type II, 3.1% had type III/SV, and 13.1% had scar
(Table 3). Of the subjects with SV (n 11), 81.8% were
male, 81.8% were professional voice users, and 90.9% had a
history of vocal abuse. The mean age was 42.3 17.2 years.
The most common other diagnoses were MTD (91.8%) and
LPR (91.8%).
When looking specifically at the dysphonia group, there were
significantly more males than females with SV (P 0.001). On
SVL, abnormalities of amplitude, mucosal wave, and vibration
were significantly more common in the SV (Table 4). The percentage of patients with MTD was slightly higher in the SV
group (100%) than the non-SV group (96.3%), but this was
not significant (P NS). Glottic insufficiency was found to
be slightly higher in the non-SV group (62.5%) than the SV
group (50%), but again this was not significant (P NS). For
the nondysphonia group, no category analyzed was found to

TABLE 2.
Vocal Complaints of the Patient in the Dysphonia Group
Vocal Complaints in the
Dysphonia Group (n 100)
Voice strain
Voice breaks
Raspy voice
Breathiness
Loss of range
Vocal fatigue
Generalized hoarseness

Percentage (%)
5
11
18
24
49
67
68

A. Morgan Selleck, et al

509

Sulcus Vocalis

TABLE 3.
Prevalence of Sulcus and Scar per Vocal Fold by Type
Type of Lesion

Sulcus Dysphonia Group (%)

Sulcus Nondysphonia Group (%)

Sulcus Total (%)

23/100 (23)
35/200 (17.5)

15/94 (16)
22/188 (11.7)

38/194 (19.6)
57/388 (14.7)

0/100 (0)
0/200 (0)

4/94 (4.3)
5/188 (2.7)

4/194 (2.1)
5/388 (1.3)

8/100 (8)
9/200 (4.5)

3/94 (3.2)
3/188 (1.6)

11/194 (5.7)
12/388 (3.1)

25/200 (12.5)

26/188 (13.8)

51/388 (13.1)

Type I
Per subject
Per vocal fold
Type II
Per subject
Per vocal fold
Type III/SV
Per subject
Per vocal fold
Scar
Per vocal fold

have a significant difference between the SV subjects and nonSV subjects, but abnormalities of amplitude, mucosal wave,
and vibration were seen more often in the SV subjects
(Table 5). Glottic insufficiency was more common in non-SV
subjects (SV 0%, non-SV 36.5%, P NS), but MTD was
more common in the SV subjects (SV 66.7%, non-SV 60.8%,
P NS).
When specifically comparing the patients with SV, no category was significantly different between the dysphonia and
nondysphonia subjects, except for abnormal objective voice
quality as expected (Table 6). For the nondysphonia group, no
patients with SV had glottic insufficiency, whereas in the
dysphonia group, 50% of the subjects with SV had glottic insufficiency. MTD was more common in the dysphonia subjects
with SV when compared with the nondysphonia SV subjects,
but this was not significant.
DISCUSSION
The prevalence of SV in our study, 5.7% per subject and 3.1%
per vocal fold, falls within the range of reported previously findings.3,5,710 Furthermore, the prevalence of type I (19.6%) and
type II (2.1%) sulcus per subject in our study falls within the
range reported previously.3,5,710 The trend toward higher

percentage reported in more recent cadaver studies may be

explained by the technique of cadaveric vocal fold evaluation
as discussed by Hsiung et al.8 Histologic examination as
opposed to gross examination provides more detailed evaluation of the vocal fold, and potentially the method of processing
the cadaver may obscure the SV.8 Prevalence rates of SV similar
to ours have been reported in cadaver studies but have not been
reported in SVL studies.
In the dysphonia group, males were significantly more likely
to have SV than females. This was not the case in the nondysphonia group. There were more males in the non-SV group,
but this was not significant (P NS). Previous studies have reported a higher prevalence of males with sulcus. Sunter et al5
reported a male-to-female ratio of 1.46, whereas Itoh et al11 reported a ratio of 2.58. For SV, all subjects with the deformity
were males in Sunter et als article. The reason for a higher ratio
of male subjects with SV is unclear, but our dysphonia subjects
showed similar findings. Further studies are needed to understand this relationship.
The etiology, congenital or acquired, of SV is still debated;
and there is evidence in the literature supporting both theories.5
Bouchayer and Cornut1 advocate the congenital theory, suggesting that SV is due to abnormal development of the fourth

TABLE 4.
Comparison of SV to Non-SV Subjects in the Dysphonia Group
Category
Males
Professional voice users
Vocal abusers
Muscle tension dysphonia
Vocal fold mass
Reinkes edema
Abnormal objective voice quality
Decreased amplitude
Decreased waveform
Hypodynamic motion
Glottic insufficiency
* Significant P < 0.05.

SV Subjects, % (n)

Non-SV Subjects, % (n)

P Value

100 (8)
75 (8)
87.5 (8)
100 (8)
25 (8)
25 (8)
100 (8)
100 (9)
100 (9)
100 (9)
50 (8)

37.5 (80)
72.5 (80)
96.3 (80)
96.3 (80)
37.5 (80)
43.8 (80)
100 (80)
59.4 (160)
59.4 (160)
60 (160)
62.5 (80)

0.001*
1.0
0.322
1.0
0.705
0.459
N/A
0.013*
0.013*
0.014*
0.706

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Journal of Voice, Vol. 29, No. 4, 2015

TABLE 5.
A comparison of SV to Non-SV Subjects in the Nondysphonia Group
Category
Males
Professional voice users
Vocal abusers
Muscle tension dysphonia
Vocal fold mass
Reinkes edema
Abnormal objective voice quality
Decreased amplitude
Decreased waveform
Hypodynamic motion
Glottic insufficiency

SV Subjects, % (n)

Non-SV Subjects, % (n)

P Value

33.3 (3)
100 (3)
100 (3)
66.7 (3)
0 (3)
66.7 (3)
100 (3)
100 (3)
100 (3)
66.7 (3)
0 (3)

66.7 (74)
81.1 (74)
83.8 (74)
60.8 (74)
32.4 (74)
37.8 (74)
100 (74)
52.7 (148)
52.7 (148)
53.4 (148)
36.5 (74)

1.0
1.0
1.0
1.0
0.548
0.557
N/A
0.249
0.249
1.0
0.548

and sixth brachial arches. Other authors suggest an acquired etiology because of the potential association with other laryngeal
pathology and vocal abuse.7,12 Sunter et al5 showed more SV in
adult patients and no SV in patients aged younger than 15 years,
but there are also studies reporting pediatric cases further
confusing the issue.1,13 It may be challenging to perform rigid
SVL in children; thus, the diagnosis of subtle laryngeal
findings like SV may be reported less frequently in the
pediatric population. Variability in age and unknown etiology
make defining a subject population difficult.
We chose to exclude patients with a prior history of laryngeal
surgery, as phonosurgery is well-documented cause of vocal
fold scarring, which might be mistaken for sulcus. Furthermore,
we felt that if SV were truly a congenital lesion, including patients with a history of laryngeal surgery would confound our
results. We also excluded all patients with a history of trauma,
except for those with possible phonotrauma vocal abuse such as
this was felt to be a potential etiology of SV.7,12 Previous
noncadaver studies have evaluated patients with a history of
vocal fold surgery, as well as intubation and vocal abuse.3 Unless postlaryngectomy vocal folds were used, history regarding
vocal abuse and laryngeal surgery was unlikely to be available
in most cadaver studies. Presuming there is uncertainty about

the etiology, our study population was designed to evaluate

SV regardless of etiology and eliminate potential confounding
factors.
By using live subjects, we were able to evaluate for the associated SVL findings classically attributed to SV and review subject histories. Operative evaluation and histopathologic
evaluation in addition to SVL would be ideal to confirm the
diagnosis and identify occult lessons such as mucosal bridges.14
To standardize and improve the diagnostic process within the
constraints of our study, SVL videos were rereviewed to
make a consensus diagnose. Only recent, rigid SVL videos
with higher quality images were used to improve the accuracy
of diagnosis.
For subjects with SV in the dysphonia and nondysphonia
group, abnormalities of vibration and hyperfunctional behavior
were more common, and this difference was significant for the
dysphonia group. Interestingly, SV subjects were less likely to
have glottic insufficiency although the differences were not significant. We believe the higher incidence of glottic insufficiency
in the non-SV group may be related to trends of a higher
percentage of vocal fold masses in this group (Tables 4 and
5) and higher percentage of compensatory MTD in the SV
subjects (Tables 4 and 5). When examining SV subjects,

TABLE 6.
Comparison of SV Subjects in the Dysphonia and Nondysphonia Groups
Category
Males
Professional voice users
Vocal abusers
Muscle tension dysphonia
Vocal fold mass
Reinkes edema
Abnormal objective voice quality
Decreased amplitude
Decreased waveform
Hypodynamic motion
Glottic insufficiency
* Significant P < 0.05.

SV Nondysphonia Subjects, % (n)

SV Dysphonia Subjects, % (n)

P Value

33.3 (3)
100 (3)
100 (3)
66.7 (3)
0 (3)
66.7 (3)
0 (3)
100 (3)
100 (3)
66.7 (3)
0 (3)

100 (8)
75 (8)
87.5 (8)
100 (8)
25 (8)
25 (8)
100 (8)
100 (9)
100 (9)
100 (9)
50 (8)

0.055
1.0
1.0
0.273
1.0
0.491
0.006*
N/A
N/A
0.250
0.236

A. Morgan Selleck, et al

511

Sulcus Vocalis

Hirano et al frequently found incomplete glottic closure,

decreased amplitude, and hypodynamic mucosal wave, but
these abnormalities were not always seen.15
Histopathologic studies discussed previously in this
article, as well as our study, suggest that SV may be more
common than previously suggested, and the degree of symptoms may at least partly be related to the compensatory behaviors developed by the patient. Compensatory strategies,
such as MTD, make it difficult to draw absolute conclusions
about the characteristics associated with SV, but larger
studies might be able to identify additional differences in
SVL findings. Regardless, clinicians should be aware of
the possibility of these defects in patients with and without
dysphonia.
CONCLUSIONS
The prevalence of SV was determined to be 3.1% (per vocal
fold) and 5.7% (per subject), which is consistent with previous
reports. Most SVL findings in our study were not significantly
different between those with and without SV. Higher frequencies of male gender and waveform abnormalities were
seen in the SV subjects, and this was significant for the
dysphonia group only. Compensatory changes may account
for the wide range of vocal complaints, and all patients examined using SVL should be evaluated for the presence of SV
regardless of the severity of their vocal complaints.

2.

3.

4.
5.

6.

7.
8.

9.
10.
11.
12.
13.
14.

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