return to: Management of Specific Voice Disorders

see: Case example - Vocal Process Granuloma; Vocal Process Granuloma (Contact Granuloma) Treated with KTP Laser

see also anatomy of laryngeal muscles: Laryngeal EMG (Electromyography) Anatomy and Video

GENERAL CONSIDERATIONS

1. Vocal Process Granuloma = benign lesions of the posterior glottis most commonly centered over the cartilaginous vocal process
   1. Differential Diagnosis of  proliferative tissue emanating from the vocal process
      1. Vocal process granuloma (also called: contact ulcer, contact granuloma, arytenoid granuloma, peptic granuloma)
      2. Tumor
         1. Squamous cell carcinoma
         2. Rare tumors: example = hemangiopericytoma, neuroendocrine carcinoma
      3. Rare process that also involve other laryngeal subsites
         1. Infective: tuberculosis, histoplasmosis, coccidioidomycosis, blastomycosis, syphilis, leprosy, scleroma
         2. Auto-immune: Granulomatosis with polyangiitis, Crohn's disease
   2. Pathology of vocal process granuloma
      1. Epithelial hyperplasia
      2. Underlying granulation tissue
2. Etiology = Injury to the posterior glottis
   1. Mechanical
      1. Vocal Trauma
         1. Carroll (2010) compensatory to glottic insufficiency
         2. Damrose (2008) 6 of the 7 pts with refractory granuloma requiring botox developed an URI with significant coughing prior to onset of symptoms
         3. different from other series where dominant etiology felt to be LPR or voice overuse
      2. Intubation Injury
         1. Surgical trauma
   2. Inflammatory
      1. Gastroesophageal (laryngopharyngeal) reflux
      2. Infection
      3. Postnasal drainage
      4. Allergic
      5. Idiopathic
3. Non-Operative Management
   1. Voice Therapy
   2. Anti-reflux Measures
   3. Systemic Steroids
   4. Antibiotics
   5. Inhaled steroids
      1. Hillel (2010)
4. Operative Management  (see Case example - Vocal Process Granuloma)
   1. Resection (Suspension Microlaryngoscopy)
   2. Botulinum neurotoxin A injection (see:Botulinum Neurotoxin A Injection) 
      1.  Thyroarytenoid (TA) / Lateral cricoarytenoid (LCA) injections
         1. Nasri (1995) (complete resolution of granulomas) - 10-15 U TA/LCA injection: breathiness for 2 to 5 months  some injections unilateral, others bilateral
         2. 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
         3. 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)
         4. Pham (2004) 15 U of TA injection ipsilateral (only one of 6 with breathy voice  
      2. Interarytenoid injections
         1. see Yilmaz 2013 with good diagrams of aggressive botox injection to include TA, LCA and IA.
         2. see Fink 2013 injection of interarytenoid (IA) muscle only
            1. 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)
            2. Clinical observation that TA injection still permitted the posterior vocal folds to touch
            3. 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. 4/8 experience mild breathiness; none with dysphagia or alteration in diet
   3. Injection laryngoplasty to augment membranous vocal fold (see: Injection Laryngoplasty for Vocal Fold Paralysis and Glottic Incompetence)
   4. In-office KTP laser treatment
      1.  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"
         1. 26 patients underwent a total of 43 laser treatments 
         2. 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
         3. 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
         4. a decrease in the size was observed in 96.2% of cases with complete resolution in 73.1% (median f/u 9.5 months)
5. Consent for Surgery
   1. Per specific procedure (ie microdirect laryngoscopy)
   2. Identify high risk of recurrence

NURSING CONSIDERATIONS

1. Per specific procedure (ie microdirect laryngoscopy)

OPERATIVE PROCEDURE

1. (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