Ectopic Salivary Gland Found in the Vocal Cord: A Rare Case.

Introduction: Ectopic salivary gland is rarely found in the vocal cords; only two cases have been reported in the English literature. To the best of our knowledge, this is the third reported case of this anomaly. Case Presentation. A 78-year-old man with hoarseness two years ago visited our department. There were no other symptoms such as cough or sore throat. He had no history of smoking. Laryngeal endoscopic examination revealed a smooth mass in the anterior right vocal cord. We performed surgery under general anesthesia to remove the polyps and improve hoarseness. The histopathological specimen was reported to be salivary gland tissue. We diagnosed ectopic salivary glands of the vocal cord. Conclusion: It is necessary to consider the possibility of ectopic salivary glands as mass lesions of the vocal cords. Surgical resection is required and long-term follow-up is necessary after surgery.

Outcome of Surgery to Improve Swallowing in Patients with Lateral Medullary Syndrome: A Retrospective Cohort Study.

The study investigated surgical interventions to improve dysphagia in patients with lateral medullary syndrome (LMS), along with optimal scheduling of surgery and prognostic factors. In this retrospective, single-center cohort study, dysphagia patients with LMS who underwent surgery between January 2010 and December 2021 were enrolled. The National Outcomes Measurement System (NOMS) was used to classify swallowing function (level 1: only tube feeding, level 5: without tube feeding). Patients were divided into four groups. Groups 1 and 2, LMS onset within 1 year, and groups 3 and 4, onset after 1 year. Groups 1 and 3 had infarctions confined to the oblongata. Groups 2 and 4 had infarctions extending to the cerebellum. The primary outcome was the time to achieve NOMS ≥ 5. The final NOMS level and pathological findings were considered. Nineteen cases were included. Group 4 comprised one case and was excluded. The mean overall preoperative NOMS was 1.11. The mean time to NOMS ≥ 5 was 9.6 months (95% confidence interval: 5.04-14.2), and that to NOMS ≥ 5 was 1.67 (1.07-2.26), 11.4 (4.71-18.1), and 7.6 (5.15-10.1) months for groups 1, 2, and 3, respectively. Group 1 achieved NOMS ≥ 5 earlier than groups 2 and 3 (P = 0.01 and 0.03, respectively). The overall final NOMS value was 4.68. Fourteen patients had atrophy or fibrosis of the cricopharyngeal muscle. In conclusion, surgery was effective for effective for treating dysphagia in LMS patients. However, improvement is prolonged if > 1 year has passed since onset or the infarction extended to the cerebellum.

Post-intubation laryngeal injury after COVID-19 treatment causing dyspnea: A report of six cases.

Severe cases of COVID-19 often require orotracheal intubation (OTI) and mechanical ventilation, and post-intubation laryngeal injury (PI-LI) is one of the important complications of OTI. Some studies have claimed that the frequency of PI-LI may be higher in COVID-19 patients as compared with that in non-COVID-19 patients, because of the larger size of endotracheal tube used, the longer OTI time, use of prone positioning of the patients, etc. Herein, we describe six cases of PI-LI who presented with dyspnea after recovering from COVID-19. Five of the patients were male and the median OTI period was 9 days. All the patients showed abnormal endoscopic findings, including posterior glottic synechiae/stenosis or subglottic/posterior glottic granulomas. Four patients required surgical intervention, including tracheostomy, laryngomicrosurgery, or laterofixation of the vocal cord. Many post-COVID-19 patients experience persistent symptoms (post-COVID-19 syndrome), including dyspnea. Two of our patients with dyspnea had been treated by internists as cases of post-COVID-19 syndrome. Therefore, we wish to underscore the need for every healthcare professional to be aware of the possibility of PI-LI after OTI, especially during the ongoing COVID-19 pandemic. Otolaryngologists should undertake endoscopic assessment of the larynx in patients presenting with dyspnea after recovering from COVID-19.

Prevention of cuff injury of the intubation tube by blunt window opening in tracheostomy.

One of the intraoperative complications of tracheostomy under general anesthesia is cuff injury of the intubation tube. In the present study, we investigated whether a blunt tracheal opening is a useful method to avoid cuff injury. A retrospective cohort study was conducted to examine patients who underwent tracheostomy under general anesthesia at a single institution from January 1, 2017 to July 31, 2021. Electrocautery was used to thin the connective tissue between the tracheal rings, and bluntly open the trachea with mosquito forceps or similar instruments. Primary outcomes included cuff injury rate, number of surgeons involved, and career as otolaryngologist at the time of surgery. The secondary outcome was perioperative complications. Of the 64 cases, 3 had cuff injuries. 2 of the 3 had cuff injuries during the creation of an anteriorly based flap. 16 surgeons were involved ranging from the first to sixth year as an otolaryngologist, with the third year of otolaryngologist being the most common. The median physician year for instructors was 18 years. The most common postoperative complication was granulation in 9 cases. There were no cases of incorrect cannula insertion or difficulty in cannula insertion. A blunt tracheal opening was considered useful as a method to prevent cuff injury.

Sex and Age Stratified Voice Data in Japanese Vocally Healthy Individuals: Vocal Capacity.

OBJECTIVE: There is no normative voice dataset regarding the vocal capacity of Japanese speakers in the English literature. We collected age- and sex-stratified data on the vocal capacity of vocally healthy Japanese speakers. METHODS: In total, 111 vocally healthy Japanese speakers (42 men and 69 women) were divided into the young (13 men and 30 women), middle-aged (18 men and 27 women), and elderly (11 men and 12 women) groups. Participants underwent duration-, intensity-, and pitch-related vocal capacity tests using either a conventional method or an aerodynamic method or both. The data obtained were statistically analyzed in terms of age and sex. RESULTS: Overall, the duration- and pitch-related parameters measured by the conventional method were generally comparable to the previous results in the literature, while duration-, pitch-, and intensity-related parameters measured by the aerodynamic method differed significantly from them. Significant sex differences were noted in all parameters in the duration-, intensity-, and pitch-related vocal capacity tests. Furthermore, significant age-related changes were observed in all parameters, except for the mean flow rate and highest pitch measured by the aerodynamic method. CONCLUSION: This study is the first to provide a sex- and age-stratified database of the normative vocal capacity data of Japanese speakers. However, further improvements will be needed in the assessment protocols, conditions, or devices used for the duration-, intensity-, and pitch-related vocal capacity tests in the aerodynamic method.

Gender- and Age- Stratified Normative Voice Data in Japanese-Speaking Subjects: Analysis of Sustained Habitual Phonations.

INTRODUCTION: There is no normative voice dataset for Japanese speakers in the English literature. We constructed age- and gender-stratified normative voice data with the assistance of vocally healthy Japanese speakers. METHODS: A total of 111 vocally healthy Japanese speakers (42 men, 69 women) were divided into young (13 men, 30 women), middle-aged (18 men, 27 women), and elderly (11 men, 12 women) groups. Participants underwent aerodynamic, acoustic, and audio-perceptual studies of sustained habitual vowel phonations, and the obtained data were statistically analyzed in terms of age and gender. RESULTS: Both gender- and age-related differences were noted in fundamental frequencies, sound pressure level, shimmer, and amplitude perturbation quotient, while only gender-related differences were noted in mean flow rate and only age-related changes were observed in subglottal pressure; laryngeal resistance; and G, R, B, and S scores of the GRBAS scale. The gender- and age-related difference data were comparable with the reported data in other languages, ethnicities, or countries. CONCLUSIONS: The present study is the first to provide a database of normative voice data of Japanese speakers. The idiosyncrasy of Japanese is considered minor in sustained habitual vowel phonations.

Multivariate Analysis of Vocal Fold Vibrations in Normal Speakers Using High-Speed Digital Imaging.

INTRODUCTION: Little is known about the normal variations in vocal fold vibrations. We conducted a prospective study on normal subjects using high-speed digital imaging (HSDI) to elucidate key parameters regarding age/gender-related normal variations. METHODS: Forty-six healthy adult volunteers were divided into young (aged ≤35 years) male, young female, elderly (aged ≥65 years) male, and elderly female subgroups. HSDI data of sustained phonation of /i/ at a comfortable pitch and loudness were obtained, and vibratory parameters were calculated using the visual-perceptual rating, laryngotopography, digital kymography, and glottal area waveform. Multivariate analysis was then performed on these parameters to clarify the subgroup-specific key parameters. RESULTS: Four key parameters were identified from a total of 83: one from visual perceptual rating and three from laryngotopography. Subgroup analyses showed that posterior-to-anterior longitudinal phase difference (PD) and high fundamental frequency (F0) were specific to young female participants. A low F0 was specific to young male participants. Large anterior-to-posterior longitudinal PD and its left-right difference were specific to elderly male participants. There were no key parameters for elderly female participants. CONCLUSIONS: Methods that can assess F0 and longitudinal PD, such as visual-perceptual rating and laryngotopography, were effective in the evaluation of normal vocal fold vibrations and their variations.

Survival case of rhinocerebral and pulmonary mucormycosis due to Cunninghamella bertholletiae during chemotherapy for acute myeloid leukemia: a case report.

A 42-year-old man diagnosed with acute myeloid leukemia complained of progressive swelling of the right side of his face with pain 11 days after the third cycle of consolidation therapy with high-dose arabinosylcytosine-cytarabine. Head and neck magnetic resonance imaging showed a mass lesion in his right maxillary sinus with parapharyngeal involvement, which included the right masseter muscle, intraorbital involvement, and an abscess in his brain. Chest computed tomography revealed peribronchial small nodules in his right upper lobe and a necrotic tumor in his right lower lobe. Molds identified as Cunninghamella bertholletiae were isolated from the necrotic ulcer. According to these results, chemotherapy for leukemia was discontinued. High-dose liposomal amphotericin (10 mg/kg/day) was initiated. Because renal dysfunction occurred, the dosage was decreased to 6 mg/kg and combined with 150 mg/day micafungin. Debridement of necrotic tissue in the right maxillary sinus and establishment of the fenestration between the sinus and oral cavity were performed. Subsequently, brain and lung lesions were surgically removed. Rhinocerebral mucormycosis was successfully treated without relapse over 3 years by a 112-day course of intravenous anti-fungal therapy and 223-day course of terbinafine and partial surgical removal, respectively, to maintain masticatory and ocular functions. To our knowledge, there has been no other report of a long-term survival case of rhinocerebral mucormycosis due to C. bertholletiae.

New Vocal Fold-shortening Procedure: External Approach to Anterior Vocal Fold Plication.

INTRODUCTION: We believe that our new procedure offers a useful external approach to anterior vocal fold plication. Vocal cord shortening by laryngomicrosurgery (LMS) involves plication of the anterior commissure, but this difficult procedure requires high-level skills. Dehiscence of the plicated location may occur postoperatively. METHODS: In the present case, we applied an innovative procedure combining vocal cord shortening by LMS with cervical incision. This facilitated plication, and no postoperative dehiscence was encountered. RESULTS: Speaking fundamental frequency (SFF) was 110 Hz at the first visit, 170 Hz after type 4 thyroplasty, 167 Hz after thyroarytenoid muscle myectomy, and 208 Hz after the present procedure, representing a good outcome. CONCLUSIONS: This procedure could be useful when the SFF is not sufficiently raised by existing procedures. The risk of postoperative dehiscence of the plicated location is low compared with LMS. CASE DETAILS: The patient consulted with a major complaint of low vocal pitch. At the first visit, SFF was 110 Hz, suggesting a male voice. In April 201X, type 4 thyroplasty was performed and successfully raised SFF to 170 Hz. As the patient did not readily pass as a woman, thyroarytenoid muscle myectomy was performed in February 201X +1 but only achieved an SFF of 167 Hz, which was considered unsatisfactory. As a result, the procedure was performed again in September 201X +1.

Real-time PCR investigation of the prevalence of Fusobacterium necrophorum in patients with pharyngitis in Japan.

PURPOSE: Recent data suggest an association between Fusobacterium necrophorum infection and pharyngotonsillitis among adolescents and adults. However, existing reports are only from North America and Europe. We aimed to identify and compare the prevalence of F. necrophorum among patients with pharyngitis and asymptomatic controls in Japan and clarify the epidemiological characteristics of pharyngitis. METHODS: Patients aged ≥16 years with pharyngitis and asymptomatic controls were prospectively included. F. necrophorum was detected by using both conventional culture methods and real-time F. necrophorum-specific PCR targeting the rpoB gene. The prevalence of ß-hemolytic streptococci was also identified and compared between groups. RESULTS: Forty-four pharyngitis patients and 31 asymptomatic controls were included. F. necrophorum was identified using PCR in 6 (13.6%) pharyngitis cases and 2 (6.5%) controls, with no significant difference (p = 0.457). The median bacterial load of F. necrophorum identified with real-time PCR was significantly higher in pharyngitis cases than in controls (p = 0.046). Patients with a high Centor Score tended to have a higher bacterial load than those with a low Centor Score and controls. In cases of pharyngitis, the prevalence of F. necrophorum was similar to that of Streptococcus pyogenes (F. necrophorum-positive: 6 [13.6%] vs. S. pyogenes-positive: 5 [11.4%], p = 0.99). CONCLUSION: F. necrophorum was similarly prevalent among pharyngitis cases as S. pyogenes in Japan. The association of higher F. necrophorum bacterial load with symptomatic pharyngitis in accordance with the previous findings from a different geographical region suggests that F. necrophorum is an important causative agent of bacterial pharyngitis.

Fusobacterium necrophorum Subsp. funduliforme in Tonsils from Various Patient Populations in Japan.

Fusobacterium necrophorum has recently been suggested to be associated with tonsillopharyngitis, peritonsillar abscess, and recurrent tonsillitis. Between the 2 subspecies of F. necrophorum, subsp. funduliforme is known to be a major human pathogen. To better understand the epidemiology of F. necrophorum subsp. funduliforme (FNSF), we studied the prevalence of FNSF in the tonsils of patients undergoing elective tonsillectomy (TE) for different indications. Adult patients who underwent elective TE from October 2014 to November 2015 were included. The tonsils were sent for aerobic and anaerobic tissue culture within 30 min of excision; the presence of FNSF was detected using PCR with gyrB primers and 16S rRNA. A total of 32 patients were enrolled. The prevalence of FNSF identified by either culture or gyrB PCR did not significantly differ between infectious and noninfectious TE indications. The constant presence of FNSF might not be associated with recurrent pharyngotonsillitis.

Characterization of Vocal Fold Vibration in Sulcus Vocalis Using High-Speed Digital Imaging.

Purpose: The aim of the present study was to qualitatively and quantitatively characterize vocal fold vibrations in sulcus vocalis by high-speed digital imaging (HSDI) and to clarify the correlations between HSDI-derived parameters and traditional vocal parameters. Method: HSDI was performed in 20 vocally healthy subjects (8 men and 12 women) and 41 patients with sulcus vocalis (33 men and 8 women). Then HSDI data were evaluated by assessing the visual-perceptual rating, digital kymography, and glottal area waveform. Results: Patients with sulcus vocalis frequently had spindle-shaped glottal gaps and a decreased mucosal wave. Compared with the control group, the sulcus vocalis group showed higher open quotient as well as a shorter duration of the visible mucosal wave, a smaller speed index, and a smaller glottal area difference index ([maximal glottal area - minimal glottal area]/maximal glottal area). These parameters deteriorated in order of the control group and Type I, II, and III sulcus vocalis. There were no gender-related differences. Strong correlations were noted between the open quotient and the type of sulcus vocalis. Conclusions: HSDI was an effective method for documenting the characteristics of vocal fold vibrations in patients with sulcus vocalis and estimating the severity of dysphonia.

High-speed Videolaryngoscopy: Quantitative Parameters of Glottal Area Waveforms and High-speed Kymography in Healthy Individuals.

OBJECTIVES: We conducted a study to obtain quantitative parameters of the vocal dynamic using high-speed videolaryngoscopy and to characterize the vocal fold vibration pattern of healthy individuals by analyzing glottal area waveforms and high-speed kymography. METHODS: Laryngeal images of 45 healthy individuals were captured using high-speed videolaryngoscopy. The open and speed quotients of the glottal area waveforms and high-speed kymography were obtained and statistically analyzed according to the gender of each individual. RESULTS: Glottal area waveforms revealed average values of 0.85 and 1.16 for open and speed quotients, respectively, for women, and 0.70 and 1.19 for men. Using high-speed kymography, quantitative parameters of open and speed quotients for women were 0.62 and 1.02, respectively, and for men were 0.57 and 1.12. By gender, a significant statistical difference emerged for open quotients obtained from both glottal area waveforms (P = 0.004) and high-speed kymography (P = 0.013). CONCLUSION: Obtained by using computational tools specifically for analyzing laryngeal images from high-speed videolaryngoscopy, quantitative parameters of glottal area waveforms and high-speed kymography in healthy individuals provide reference data and normality for future studies.

Visualization and Estimation of Vibratory Disturbance in Vocal Fold Scar Using High-Speed Digital Imaging.

OBJECTIVE: To explore the method to visualize and quantify the abnormality of vocal fold vibration in vocal fold scar (VFS) using high-speed digital imaging (HSDI). METHODS: HSDI was performed on 12 patients (2 men and 10 women) with VFS and 46 vocally healthy subjects (17 men and 29 women), and the obtained data were quantitatively evaluated by frame-by-frame analysis, laryngotopography (LTG), single-line and multiline kymography, and glottal area waveform. RESULTS: Visualization of a scarred area was feasible in 75% of VFS in the present study using LTG. Quantitative HSDI analysis revealed that VFS had poorer glottal closure (eg, larger open quotients, larger minimal glottal area), reduced vibration in a scarred area (eg, smaller mucosal wave magnitude, mucosal wave persistence, lateral peak index), and greater asymmetry (eg, amplitude difference, mucosal wave magnitude difference, lateral phase difference) than the control group. Correlation study revealed moderate correlations between HSDI-derived parameters and conventional acoustic or aerodynamic parameters (eg, period perturbation quotient). CONCLUSIONS: HSDI is considered to be useful in the diagnosis of VFS, visualization of a scarred area, and quantification of vibratory abnormality.

Relationship of Various Open Quotients With Acoustic Property, Phonation Types, Fundamental Frequency, and Intensity.

INTRODUCTION: In the present study, we examined the relationship between various open quotients (Oqs) and phonation types, fundamental frequency (F0), and intensity by multivariate linear regression analysis (MVA) to determine which Oq best reflects vocal fold vibratory characteristics. METHODS: Using high-speed digital imaging (HSDI), a sustained vowel /e/ at different phonation types, F0s, and intensities was recorded from six vocally healthy male volunteers: the types of phonation included modal, falsetto, modal breathy, and modal pressed phonations; and each phonation was performed at different F0s and intensities. Electroglottography (EGG) and sound signals were simultaneously recorded with HSDI. From the obtained data, 10 conventional Oqs (four Oqs from the glottal area function, four kymographic Oqs, and two EGG-derived Oqs) and two newly introduced Oqs (Oq(edge)+ and Oq(edge)) were evaluated. And, relationships between various Oqs and phonation types, F0, and intensity were evaluated by MVA. RESULTS: Among the various Oqs, Oq(edge)+ and Oq(edge) revealed the strongest correlations with an acoustic property and could best describe changes in phonation types: Oq(edge) was found to be better than Oq(edge)¯. Oq(MLK), the average of five Oqs from five-line multiline kymography was a very good alternative to Oq(edge)¯. EGG-derived Oqs were able to differentiate between modal phonation and falsetto phonation, but it was necessary to consider the change of F0 simultaneously. MVA showed the changes in Oq values between modal and other phonation types, the degree of involvement of intensity, and no relationship between F0 and Oqs. CONCLUSIONS: Among Oqs evaluated in this study, Oq(edge)+ and Oq(edge) were considered to best reflect the vocal fold vibratory characteristics.

Quantification of Vocal Fold Vibration in Various Laryngeal Disorders Using High-Speed Digital Imaging.

OBJECTIVE: To quantify vibratory characteristics of various laryngeal disorders seen by high-speed digital imaging (HSDI). METHODS: HSDI was performed on 78 patients with various laryngeal disorders (20 with polyp, 16 with carcinoma, 13 with leukoplakia, 6 with vocal fold nodule, and 33 with others) and 29 vocally healthy subjects. Obtained data were quantitatively evaluated by frame-by-frame analysis, laryngotopography, digital kymography, and glottal area waveform. RESULTS: Overall, patients with laryngeal pathologies showed greater asymmetry in amplitude, mucosal wave and phase, smaller mucosal wave, and poorer glottal closure than vocally healthy subjects. Furthermore, disease-specific vibratory disturbances that generally agreed with the findings in the literature were quantified: comparing polyp with nodule, differences were noted in longitudinal phase difference, amplitude, and mucosal wave. In comparison with leukoplakia and cancer, nonvibrating area was more frequently noted in cancer. CONCLUSIONS: The HSDI analysis of various voice disorders using multiple methods can help phonosurgeons to properly diagnose various laryngeal pathologies and to estimate the degree of their vocal disturbances.

Quantitative Analysis of Vocal Fold Vibration in Vocal Fold Paralysis With the Use of High-speed Digital Imaging.

INTRODUCTION: The goal of this work was to objectively elucidate the vibratory characteristics of vocal fold paralysis (VFP) using high-speed digital imaging (HSDI). METHODS: HSDI was performed in 29 vocally healthy subjects (12 women and 17 men) and in 107 patients with VFP (40 women and 67 men). Then, the HSDI data were evaluated by visual-perceptual rating, single-line kymography, multiline kymography, laryngotopography, and glottal area waveform analysis. RESULTS: Patients with VFP compared with vocally healthy subjects revealed more frequent incomplete glottal closure, greater asymmetry in amplitude, mucosal wave, frequency, and phase, as well as larger open quotient, smaller speed index, larger maximal and minimal glottal area, and smaller glottal area difference. Paralyzed vocal folds in VFP revealed reduced mucosal wave than nonparalyzed vocal folds in VFP or in intact vocal folds in vocally healthy subjects. CONCLUSIONS: HSDI was effective in documenting the characteristics of vocal fold vibrations in patients with VFP and in exploring the vibratory disturbance for estimating the severity of dysphonia.

An Aerodynamic Study of Phonations in Patients With Parkinson Disease (PD).

BACKGROUND: The precise comparison of the voice characteristics of Parkinson disease (PD) patients with age-matched normal subjects is still one of the important research projects. The present study aimed at comparing the voice characteristics in sustained phonations of PD patients with an age-matched control group. METHODS: The subjects were 30 Japanese PD patients (15 males and 15 females). The control group consisted of 30 age-matched normal Japanese subjects (15 males and 15 females). Each subject was required to phonate into a mouthpiece attached to Vocal Function Analyzer (PS-77E; Nagashima Medical Instrumental Corporation, Tokyo, Japan) with the airway interruption system, and expiratory lung pressure, mean flow rate, fundamental frequency and intensity of voice, and pitch range were measured. Maximum phonation time was also assessed. RESULTS: The highest pitch level was significantly lower in the PD group than that of the control group in both sexes, whereas the lowest pitch level was significantly higher in the PD group only in males. In both sexes, the pitch range was significantly narrower in the PD group than in the control group. There was no significant difference in intensity, mean flow rate, expiratory pressure, or maximum phonation time between the two groups, for both males and females. CONCLUSION: Only remarkable difference in the voice characteristics between PD patients and age-matched normal elderlies was limited to the narrowing of the pitch range in PD patients. The restriction in pitch regulation in PD patients was considered to be because of difficulty in reciprocal control of the laryngeal muscles secondary to latent rigidity.

Vocal Fold Vibration in Vocal Fold Atrophy: Quantitative Analysis With High-Speed Digital Imaging.

INTRODUCTION: Vocal fold vibrations of vocal fold atrophy (VFA), a rapidly increasing voice disorder owing to worldwide societal aging, have not been clarified by high-speed digital imaging (HSDI). METHODS: The HSDI method was performed on 46 patients (33 males and 13 females) with VFA and 20 vocally healthy subjects (8 males and 12 females), and the obtained data were quantitatively evaluated by frame-by-frame analysis, laryngotopography, single- and multi-line kymography, and glottal area waveform. RESULTS: Overall, patients with VFA revealed larger open quotients, larger lateral phase difference, larger integral glottal width (the average glottal width over a glottal cycle), and smaller speed index than vocally healthy subjects. Some gender difference was noted: in males, lateral phase difference was not significant; and in females, integral glottal width and speed index were not significant. Correlation study revealed moderate correlations between HSDI-derived parameters and conventional acoustic or aerodynamic parameters. CONCLUSIONS: The combination of multiple HSDI analysis methods was effective in documenting the characteristics of vocal fold vibrations in VFA. The knowledge of general vibratory characteristics and gender difference is beneficial for the appropriate clinical care of VFA.

Patients' perceptions of vocal problems: results from a survey in the Tokyo area.

Laryngoscopy in cases of sulcus vocalis reveals bowed vocal folds, resulting in a spindle-shaped chink with glottal incompetence. The anatomic and functional problems and resulting incomplete glottal closure during phonation lead to the presenting symptoms of breathy hoarseness, decrease in maximum phonation time (MPT), and vocal fatigue. These symptoms, however, have been reported from the physician's viewpoint, not the patient's. Furthermore, no standardized guidelines for the treatment of sulcus vocalis have been established. Because the general attitude toward sulcus vocalis appears to have become 'It is only a vocal problem and does not significantly affect the patient's well-being,' knowledge of sulcus vocalis has decreased and knowledge about choices of therapy remain limited. We therefore conducted an epidemiological questionnaire survey on this pathological condition in voice clinics in seven hospitals in the Tokyo area to establish preliminary guidelines for the management of sulcus vocalis, in reference to the opinion of the patients. Here we report the summary of our preliminary study 'a survey for sulcus vocalis' and suggest guidelines for the management of such pathological conditions. Although these management guidelines may result in improvement in the symptoms of sulcus vocalis, patients and physicians should be aware that treatment of this condition is difficult and improvement is not guaranteed.