Nonoperative treatment of laryngeal granuloma. (Laryngoscopic Clinic).

A 60-year-old man with a history of noninsulin-dependent diabetes mellitus, hypertension, and hypothyroidism also had a 6-year history of throat problems, a "gravelly and husky" voice, a loss of singing range at the high end, and vocal fatigue. The vocal demands of his occupation (director of dining services at a small college) were extensive; he also sang at his church and lectured at religious conferences. The patient experienced occasional right-sided throat pain, morning and evening throat soreness, excessive throat clearing, and a bitter taste in the morning. He had been taking omeprazole twice daily for the preceding 2 years, but it resulted in only a slight alleviation of his symptoms.

On strobovideolaryngoscopy, the patient was noted to have signs of severe laryngopharyngeal reflux and a large biloed granuloma overlying the medial surface of the vocal process of the right arytenoid (figure 1). A 24-hour pH monitoring test obtained while the patient was taking 20 mg of omeprazole twice daily revealed four episodes of proximal acid exposure. Because the patient had exhibited signs of continuing laryngeal acid exposure and damage, we increased the dosage of omeprazole to 40 mg twice daily and added ranitidine at 300 mg at bedtime to decrease nighttime acid breakthrough. (1) The patient was also counseled on behavioral modifications.

Follow-up strobovideolaryngoscopy 2 months later revealed a substantial decrease in the size of the mass as well as a diminution of the arytenoid erythema and edema and in the extent of the posterior cobblestoning (figure 2). Serial follow-up examinations were conducted, and 15 months after the patient's initial visit, the mass had disappeared and the reflux signs had abated (figure 3).

This case demonstrates that even severe granulomas can be treated successfully with an adequate antireflux regimen. The adequacy of treatment can be determined by 24-hour pH monitoring. (2) If a laryngeal granuloma fails to respond to aggressive medical therapy, laryngoscopy with biopsy is indicated to confirm the diagnosis. (3) Surgical therapy of laryngeal granulomas is frequently unsuccessful without adequate medical control of laryngopharyngeal reflux.

References

(1.) Peghini P, Katz P, Castelt D. Bedtime ranitidine decreases gastric acid secretion and eliminates esophageal acid exposure overnight in a patient with Barrett's esophagus taking omeprazole 20 mg BID [abstract]. Am J Gastroenterol 1997;92:1723.

(2.) Katzka DA, Paolctti V. Leite L, Castell DO. Prolonged ambulatory pH monitoring in patients with persistent gastroesophageal reflux disease symptoms: Testing while on therapy identifies the need for more aggressive antireflux therapy. Am J Gastroenterol 1996;91:2110-3.

(3.) Hoffman HT, Overholt E, Karnell M, MeCulloch TM. Vocal process granuloma. Head Neck 2001;23:1061-74.

From the Department of Otolaryngology--Head and Neck Surgery, Thomas Jefferson University, Philadelphia.