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
- Voice therapy implemented
- Gastroenterology evaluation
- GI consult: negative 24 H pH probe off PPI's; endoscopy: intact Nissen wrap, no signs of reflux esophagitis
- Despite negative GI evaluation - continued use of bid PPI's
- Options for surgical management discussed
- Microdirect laryngoscopy with steroid injection to base of lesion, scissors ('cold steel') resection
- Adjuvant therapy: botox injection vs injection laryngoplasty to improve membranous vocal fold closure
- February 2006 - Microdirect laryngoscopy
- 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)
- Resect (scissors) granuloma (flush with adjacent normal tissue)
- Injection laryngoplasty to L membranous vocal cord ('3 clicks' of gelfoam = 1 gram mixed with 4 cc saline)
- 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)
- Recurrence (smaller size) noted 03-02-06
- 04-13-06
- 08-24-06
- 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)
- Resect (scissors) granuloma (flush with adjacent normal tissue)
- 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)
- Surgical Photos:
- 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
- November 16, 2006
- Voice nearly back to normal, granuloma still present, but smaller than Sept. photos pending from voice clinic
- March 13, 2007 - Voice normal, granuloma present
- Sept 11, 2007
- Voice normal, granuloma present, but smaller
- Voice normal, granuloma present, but smaller
- Oct 9, 2008
- Voice normal (voice clinic eval), granuloma gone
- Nov 3, 2009 - Voice normal, no evidence for the granuloma
- Success in resolution ascribed by the patient to:
- Successive surgeries in 2006
- Continued application of vocal behavior imprinted from voice therapy
- Continued use of omeprazole (1/2 hour before breakfast and 1/2 hour before dinner)
- Success in resolution ascribed by the patient to:
-
Followup December 2013 with no voicing or swallowing problems