Case histories: Congenital disorders: Furrow

• History
• Vocal Capability Testing
• Laryngeal exam
• Treatment
  • Medical
  • Behavioral
  • Surgical

History

Complaints

• Lifelong hoarse voice quality that has gradually worsened.
• Noted to be a fairly significant problem ten years ago.
• He can’t yell very well.
• He cannot be heard and he is unable to complete long sentences in one breath.
• His voice is hoarse in quality and soft-spoken.
• His voice is generally better in the morning,
• though the voice sometimes improves with continued use.
• Previously diagnosed with nodules - speech therapy did not help at that time

Medical history

• Singing: none
• Smoking: none
• Fluids:
  • Water: 5 cup per day
  • Caffeine: 2 caffeinated beverages/day
  • Alcohol: 0 glass per month

Character

• Talkativeness: 3 on a scale of 7 (1 quiet, 7 talkative)
• Loudness: 3 on a scale of 7 (1 is soft, 7 is loud)
• Vocal commitments at Work: 2 hours per workday

Vocal capabilities

• Reading pitch: Forced with harmonics and overtones
• Anchor pitch: A3 (falsetto like or female pitch)
• Range: G3 – E4 (very abbreviated range)
• Max phonation: >20 seconds @ B3
• Loudness: excellent
• Swelling tests: negative, though he sounds like he has a gap throughout his range
• Neurogenicity: none
• Psychogenicity: none
• Valving: fair
• Respiration: normal

Stroboscopic Examination of the Larynx

Evaluation	Rigid endoscopy
	During breathing, the vocal folds open widely and the furrow on the inside or medial margin is visible as a groove (arrows). Click on photo for high resolution view.
	The prephonatory gap is the instant just before the vocal cords begin vibrating. There is bowing with the large central gap present. In addition the false vocal folds are squeezed quite tightly together as the patient attempts to close the vocal cords as much as possible. Click on photo for high resolution view.
	Closed phase during stroboscopy. The vocal folds do not even meet in the midline so a lot of air escapes while making a sound. The pitch is E3, a normal speaking pitch for a male. The left vocal fold is vibrating at a harmonic with a central musical node of vibration suggesting a source for the overtones in his voice. Again the false vocal folds are squeezed tightly almost covering the true vocal folds. Click on photo for high resolution view.

Evaluation	Flexible endoscopy
	Intralaryngeal view demonstrates wispiness of vocal folds with very capacious or sunken in laryngeal ventricles (arrows). The vocal cord muscle (thryoarytenoid) is very atrophic. Click on photo for high resolution view.
	Closed phase during stroboscopy for the lower lip of the vocal fold with a central air gap. Click on photo for high resolution view.
	Open phase during stroboscopy. The left vocal fold seems weaker than the right and here is buckling out or fluttering in the wind, compared to the more subdued vibrations on the right. It is as if the left vocal cord lacks the tension present in the right. Click on photo for high resolution view.

Treatment

1. My protocal has been to try voice building initially, since the visible bowing may represent muscular atrophy.
2. I wondered in this case if there was a loss of innervation or nerve supply to the very bowed vocal muscle (thyroarytenoid) and performed an EMG. There was a normal hookup of the nerve to the vocal muscle.
3. If voice building fails (after a three to six week trial), then I inject collagen or place laryngeal implants to improve the bulk of the vocal folds and bring the edges closer together.
4. The furrow may represent an adhesion of the lining of the vocal fold mucosa to the underlying muscle. The normal vocal fold is three layers with a lubricating layer in between the mucosa and the muscle.
5. I have seen Dr. Ford perform z-plasties on the vocal fold edge in this type of case, though I remain unconvinced of it’s effectiveness. He feels the cause of the disorder is scarring.