Monday, April 10, 2017

Return to: Management of Specific Voice Disorders

See also:

General Considerations

  • Vocal Process Granuloma = benign lesions of the posterior glottis most commonly centered over the cartilaginous vocal process
    • Differential Diagnosis of  proliferative tissue emanating from the vocal process
      • Vocal process granuloma (also called: contact ulcer, contact granuloma, arytenoid granuloma, peptic granuloma)
      • Tumor
        • Squamous cell carcinoma
        • Rare tumors: example = hemangiopericytoma, neuroendocrine carcinoma
      • Rare process that also involve other laryngeal subsites
        • Infective: tuberculosis, histoplasmosis, coccidioidomycosis, blastomycosis, syphilis, leprosy, scleroma
        • Auto-immune: Granulomatosis with polyangiitis, Crohn's disease
    • Pathology of vocal process granuloma
      • Epithelial hyperplasia
      • Underlying granulation tissue
  • Etiology = Injury to the posterior glottis
    • Mechanical
      • Vocal Trauma
        • Carroll (2010) compensatory to glottic insufficiency
        • Damrose (2008) 6 of the 7 pts with refractory granuloma requiring botox developed an URI with significant coughing prior to onset of symptoms
        • different from other series where dominant etiology felt to be LPR or voice overuse
      • Intubation Injury
        • Surgical trauma
    • Inflammatory
      • Gastroesophageal (laryngopharyngeal) reflux
      • Infection
      • Postnasal drainage
      • Allergic
      • Idiopathic
  • Non-Operative Management
    • Voice Therapy
    • Anti-reflux Measures
    • Systemic Steroids
    • Antibiotics
    • Inhaled steroids
      • Hillel (2010)
  • Operative Management  (see Case example - Vocal Process Granuloma)
    • Resection (Suspension Microlaryngoscopy)
    • Botulinum neurotoxin A injection (see:Botulinum Neurotoxin A Injection) 
      • Thyroarytenoid (TA) / Lateral cricoarytenoid (LCA) injections
        • Nasri (1995) (complete resolution of granulomas) - 10-15 U TA/LCA injection: breathiness for 2 to 5 months  some injections unilateral, others bilateral
        • Orloff (1999)  5 - 20 U  TA injection - mild to moderate breathiness in 7 of 8 patients (4 required re-injection) some were unilateral, some were bilateral injections
        • Damrose (2008)  5.0 to 7.5 units given to each vocal cord (point-touch technique) bilateral injections, sometime multiple times with overall dose - 10-25 U total dose (all 7 pts with breathy voice)
        • Pham (2004) 15 U of TA injection ipsilateral (only one of 6 with breathy voice  
      • Interarytenoid injections
        • see Yilmaz 2013 with good diagrams of aggressive botox injection to include TA, LCA and IA.
        • see Fink 2013 injection of interarytenoid (IA) muscle only
          • Rationale: interarytenoid (in canine model) serves to mainly adduct the posterior true vocal fold - hypothesize chemodenervation of IA provide therapeutic benefit while decrease side effects (breathiness, dysphagia)
          • Clinical observation that TA injection still permitted the posterior vocal folds to touch
          • Current study of IA injection done under local anesthesia (except one done with excision due to airway concern) with transthyroid hyoid injection with concurrent flex scope control in 8 patients with botox (5 u in two pts, 7.5 u in two pts, 10 u in two pts, and 15 u in one pt) supplemented with steroid injection to base of granuloma in 4 of the eight
          • 4/8 experience mild breathiness; none with dysphagia or alteration in diet
    • Injection laryngoplasty to augment membranous vocal fold (see: Injection Laryngoplasty for Vocal Fold Paralysis and Glottic Incompetence)
    • In-office KTP laser treatment
      • Dominguez et al (2017) reported in-office KTP ablation of vocal fold granulomas - with their findings reported "This may suggest that recalcitrant VPGs may be better addressed with KTP laser treatment rather than conservative measures"
        • 26 patients underwent a total of 43 laser treatments
        • average number of joules per KTP treatment was 182.51 with a wide range from 9 to 1178 joules. The mode of treatment (contact/non-contact/epithelial blanching as per et al (see KTP Laser for the Larynx) was not reported
        • the mean wattage was 30.72 +/- 7 and the pulse width 21.21 +/- 4.39 with two to three pulses per second used in each case; no biopsy or debulking was done
        • a decrease in the size was observed in 96.2% of cases with complete resolution in 73.1% (median f/u 9.5 months)
  • Consent for Surgery
    • Per specific procedure (i.e. microdirect laryngoscopy)
    • Identify high risk of recurrence

Nursing Considerations

  • Per specific procedure (i.e. microdirect laryngoscopy)

Operative Procedure

see Case example - Vocal Process Granuloma

References

Hoffman HT, Overholt E, Karnell M and McCulloch TM: Vocal Process Granuloma. Head & Neck  Dec 2001 1061-1073

Yilmaz T, Suslu N, Gamze Atay, Ozer Serdar, Gunavdin RO, and Bajin MD: Recurrent Contact Granuloma: Experience with Excision and Botulinum Injection JAMA Otolaryngol Head Neck Surg. 2013;139(6):579-583

Fink DS, Achkar J, Franco RA, Song PC: Interarytenoid botulinum toxin injection for recalictrant vocal process granuloma. Laryngoscope 2013 Dec;123(12):3084-7

Nasri S, Sercarz JA, McAlpin T, Berke GS: Treatment of vocal fold granulomas using botulinum toxin type A. Laryngoscope 1995;185:585-588

Orloff LA, Goldman SN. Vocal Fold granulomas: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg 1999;121:410-413

Pham J, Sheng Y, Organ M, Stucker F, Nathan C: Botulinum toxin: helpful adjunct to early resolution of laryngeal granulomas. J Laryngol otol 2004; 118-781-785

Damrose EJ, Damrose JF: Botulinum toxin as adjucntive tehrapy in regfractory laryngeal granuloma J Laryngol Otol 2008;122:824-828

Hillel AT, Lin LM, Samlan R, Starmer H, Leahy K, Flint PW: Inhaled triamcinolone with proton pump inhibitor for treattment of vocal process granulomas: a series of 67 granulomas. Ann Otol Rhinol Laryngol 2010 May;119 (5):325-30

Carroll TL, Gartner-Schmidt J, Statham MM, Rosen CA: Vocal process granuloma and glottal insufficiency: an overlooked etiology? Laryngoscope. 2010 Jan;120(1):114-20

Chmielewska M and Akst L: Dysphonia associated with the use of inhaled corticosteroids. Current Opinion in Otolaryngology & Head and Neck Surgery (2015) Vol 23 issue 3 p 255

Dominguez LM, Brown RJ, and Simpson C: Treatment of Outcomes of In-Office KTP Ablation of Vocal Fold Granulomas  Annals of Otology, Rhinology & Laryngology 2017, Vol 126(12) 829-834