Conservative treatment of an obstructing vocal fold granuloma.

A 59-year-old woman came to our laryngology subspecialty clinic complaining of a 6-month history of hoarseness. Upon questioning, she reported that the pitch of her voice had notably deepened during the previous 2 years She also noted that her breathing had become more labored during the previous month. She denied any symptoms of gastroesophageal reflux. Her social history was significant for a 60 pack-year smoking habit and a distant history of frequent alcohol consumption.

Our examination revealed that her voice was strained and rough in quality with frequent periods of breathiness She had marked phonation breaks, and her pitch was lower than that of the typical female voice (123 to 156 Hz). Videostroboscopy revealed that a bulky lesion or her right true vocal fold was partially obstructing the airway (figure 1). Significant Reinke's edema and pachydermia were also present. No mucosal wave was noted on the right.

[FIGURE 1 OMITTED]

We suspected that the lesion was a granuloma ant placed the patient on proton-pump inhibitor therapy with twice-a-day dosing. We also emphasized lifestyle modification--specifically, the elimination of tobacco products. In light of the size of the lesion and her long history of smoking, we made plans to take her to the operating room for definitive diagnosis and treatment.

One month passed before the patient returned for her preoperative visit. She said that she had significantly decreased her use of tobacco and that her subjective voice symptoms had improved. She no longer had any obstructive symptoms. We noted less strain on phonation and decreased breathiness. The patient's pitch also had improved to between 130 and 168 Hz. The lesion on the right true vocal fold had resolved, and the overall appearance of both vocal folds had improved (figure 2). Furthermore, the mucosal wave had returned on the right side. We decided to postpone surgical intervention and to continue to monitor closely.

[FIGURE 2 OMITTED]

This case illustrates the effectiveness of treating a large vocal fold granuloma with a proton-pump inhibitor and lifestyle modification.

From the Department of Otolaryngology--Head and Neck Surgery, Brooke Army Medical Center, Ft. Sam Houston, Tex.