Multiple bilateral vocal fold cysts and recurrent pyogenic 'granuloma'.

A 45-year-old executive came to the office with complaints of choking and gagging while speaking. Following episodes of coughing, he noticed hoarseness. These symptoms had been present for several months. The patient also complained of voice fatigue and a mild discomfort while swallowing solids or liquids. He had quit smoking 12 years earlier, after a 15 pack-year history. He admitted to throat clearing, a sensation of liquid in his throat, and other symptoms of laryngopharyngeal reflux. He also had mild allergies, which had been treated intermittently with antihistamines.

Strobovideolaryngoscopy revealed a mild stiffness of both vibratory margins, which was worse on the right, and the presence of structural lesions. During gentle inspiration, a large mass on the right filled the posterior glottis (figure 1). The mass was based on a stalk that was attached in the region of the right vocal process. There were also varicosities on the superior surface of both vocal folds, including a vessel that coursed toward the vibratory margin into a small cyst on the right.

During expiration, the small cyst and its associated vessel could be seen more easily (figure 2). There was a contact swelling more anteriorly on the right and two vocal fold cysts on the left. Also, the large pyogenic granuloma was displaced superiorly out of the posterior glottis. There was a marked erythema of the posterior portion of the larynx, which was caused by reflux.

After voice therapy and intensive antireflux therapy (which resulted in some improvement, but not a complete resolution of symptoms or signs), the pyogenic granuloma and cysts were removed. The patient recovered well initially, but his pyogenic granuloma recurred despite intensive medical antireflux treatment and continued voice therapy. Strobovideolaryngoscopy revealed a pattern of lateral-cricoarytenoid-dominant adduction. The patient was returned to the operating room, and the recurrent granuloma was removed. Botulinum toxin was injected into the right lateral cricoarytenoid muscle. The patient healed well and has had no further difficulty.

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