The ´comma sign` and its relevance for the assessment of vocal fold movement disorders

Susanne Fleischer, Anna-Katharina Licht, Markus M. Hess.

In cases with normal bilateral innervation of the vocal folds and no relevant morphological asymmetries of the larynx, phonatory adduction usually results in a symmetrical medial compression and symmetrical contact of the arytenoids. Thus, in most cases the medial contact-area of the arytenoids is in asagittalplane. Endoscopically, the sagittal direction of the arytenoid contact-area during closing can be seen as a fine line superior to the interarytenoid region.
In patients with unilateral paresis or paralysis of the recurrent laryngeal nerve we can see a significant deviation of this interarytenoid line from the sagittal plane. The line is oblique and points posteriorly to the active side and anteriorly to the paralyzed side. For example, in case of paralysis of the left vocal fold, the line runs from posterior right to anterior left. When seen in conjunction with the glottis line during adduction the shape of a ´comma` is perceived (´comma-sign`). This sign seems repetitive in most cases with complete unilateral paralysis. To our experience it also can be very helpful in cases where incomplete paresis or arytenoid movement lagging is assumed. The assumed biomechanics and pathophysiology are explained in the poster.
This ´comma-sign` must be differentiated from morphological asymmetries in the arytenoid region and asymmetric corniculate or cuneiform tubercles. Furthermore one must pay attention not to misinterpret mucosal thickening folds for the interarytenoid fold.

Correspondence address:
Susanne Fleischer, MD
Department of Voice, Speech and Hearing Disorders
University Medical Center Hamburg-Eppendorf
Martinistrasse 52
D-20246 Hamburg
GERMANY
Tel: +49-(40)-42803-2865
Fax: +49-(40)-42803-6814
fleischer@uke.uni-hamburg.de