Return to Protocol: Vocal Process Granuloma

See also: Botulinum Toxin Protocols; Vocal Process Granuloma (Contact Granuloma) Treated with KTP Laser

Case history:

50 yo man who presented to our clinic in 2005 with dysphonia and a vocal fold lesion consistent with vocal process granuloma

Chronology:

1997: Onset of dysphonia without known provocative event.

1998: Resection of vocal fold lesion consistent with vocal process granuloma (vocal quality improved)

2000: Nissen fundoplication: absence of classic heartburn symptoms, but workup suggesting laryngopharyngeal reflux (LPR) - benefit from Nissen: no more raw feeling in throat; good voice until 2005

2005: Return of dysphonia after cheering at a soccer match - persisting until resection of recurrent vocal process granuloma with laser ablation at base done elsewhere

2005: Referral to the UIHC with recurrent dysphonia (G2R2B2A0S0)  

    Picture August 2005  - vocal process granuloma   

1. Voice therapy implemented
2. Gastroenterology evaluation
   1. GI consult: negative 24 H pH probe off PPI's; endoscopy: intact Nissen wrap, no signs of reflux esophagitis
   2. Despite negative GI evaluation - continued use of bid PPI's
3. Options for surgical management discussed
   1. Microdirect laryngoscopy with steroid injection to base of lesion, scissors ('cold steel') resection
   2. Adjuvant therapy: botox injection vs injection laryngoplasty to improve membranous vocal fold closure
4. February 2006 - Microdirect laryngoscopy
   1. ​Injection base of granuloma with 1.5 cc of 'kenalog 10' (diluting 1 part kenalog 40 with 3 parts of lidocaine / epinephrine mixture = 1% lidocaine with 1:100,000 epinephrine)
      1. Resect (scissors) granuloma (flush with adjacent normal tissue)
      2. Injection laryngoplasty to L membranous vocal cord ('3 clicks' of gelfoam = 1 gram mixed with 4 cc saline)
5.  Recurrence (smaller size) noted 03-02-06
   
6. 04-13-06
   
7. 08-24-06
   
8. August 30, 2006 - Microdirect laryngoscopy with Injection base of granuloma with 0.3 cc of 'kenalog 10' (diluting 1 part kenalog 40 with 3 parts of lidocaine / epineprhine mixture = 1% lidocaine with 1: 100,000 epinephrine)
   1. Resect (scissors) granuloma (flush with adjacent normal tissue)
   2. Botox (botulinum neurotoxin A) injection to left vocal fold (15 units; 2.5units/0.1cc) -  divided into two doses targeted to left TA (0.3cc=7.5 units) and left LCA (0.3cc=7.5 units)
   3. Surgical Photos:
        
9. September 22, 2006 - (4 weeks after resection and botox injection to left vocal cord) Breathy voice, incomplete glottic closure - small recurrent granuloma at a higher level
      
10. November 16, 2006
    1. Voice nearly back to normal, granuloma still present, but smaller than Sept. photos pending from voice clinic
11. March 13, 2007 - Voice normal, granuloma present
    1.   
12. Sept 11, 2007
    1. Voice normal, granuloma present, but smaller
       
13. Oct 9, 2008
    1. Voice normal (voice clinic eval), granuloma gone
14. Nov 3, 2009 - Voice normal, no evidence for the granuloma
    1. Success in resolution ascribed by the patient to:
       1. Successive surgeries in 2006
       2. Continued application of vocal behavior imprinted from voice therapy
       3. Continued use of omeprazole (1/2 hour before breakfast and 1/2 hour before dinner)
          

15. Followup December 2013 with no voicing or swallowing problems