Bilateral granuloma and varicosity in the midportion of the vocal folds. (Laryngoscopic Clinic).

A 57-year-old woman, a retired secretary, came to us with a 3-year history of intractable cough. She also complained of vocal fatigue, hoarseness, and throat "spasms." One year earlier, she began to develop intermittent hoarseness that had progressed to continuous hoarseness. She simultaneously began to experience vocal fatigue that significantly interfered with her singing, and she complained of a globus sensation, bitter taste, frequent throat clearing, and dry mouth despite proton-pump inhibitor therapy. At that time, she was diagnosed with vocal fold nodules, which were removed. Nine months later, she underwent laryngoscopy for the removal of a vocal fold polyp. The surgical specimens were read by the pathologist as granulation tissue.

On our examination, the patient's markedly pressed, somewhat breathy voice became very breathy when she relaxed her supraglottic hyperfunction. Strobovideolaryngoscopy detected two large opposing masses on the superior surfaces and striking zones of the vocal folds; these masses prevented apposition of the anterior and posterior portions of the true vocal folds (figure). Large varicose vessels were present bilaterally, but there was no evidence of acute hemorrhage. Vocal fold motion was symmetric. The masses prevented us from making an accurate stroboscopic examination of the normal portions of the vocal folds.

After an initial evaluation by a speech-language pathologist and a singing teacher, the patient was taken to the operating room for microdirect laryngoscopy. Both of her vocal folds were infused with saline and epinephrine, but this failed to separate the masses from the underlying tissues. Because of the scarring that remained from her previous surgeries, sharp dissection was required to divide the masses from the vocal ligament. After resection of both masses, the lateral varicose vessels were cauterized superficially with a [CO.sub.2] laser. Pathologic examination identified the masses as granulation tissue.

Aggressive antireflux therapy was prescribed, and because of the depth of the excision and slow mucosal healing, the patient was kept on voice rest for 2 weeks. On follow-up stroboscopic examination, she was found to have a recurrence of the right vocal fold granuloma and stiffness of the midportion of both vocal folds. She required two more microdirect laryngoscopies with resection of the recurrent granuloma and injection of a steroid into the vocal folds. The patient was also given an oral steroid taper after each of these repeat surgeries. Botox was not used. This case illustrates the difficulty of treating granuloinns of the true vocal folds and the frequent need for multiple surgeries.

From the Department of Otolaryngology. Graduate Hospital, Philadelphia, and the Department of Otolaryngology, Thomas Jefferson University, Philadelphia (Dr. Anderson and Dr. Sataloff), and the American Institute for Voice and Ear Research, Philadelphia (Ms. Hawkshaw).