Recalcitrant arytenoid granuloma.

A 37-year-old man, a software developer, presented after having undergone 3 years of treatment with multiple medications, voice therapy, and seven operations to eliminate a left arytenoid-body granuloma that caused odynophonia. He also had had laryngopharyngeal reflux for several years, for which he had been treated with a proton-pump inhibitor twice daily. Surgical excision with a C[O.sub.2] laser and cold steel instruments had both been attempted, as had intralesional steroid injection and application of mitomycin C.

The patient's granuloma was clearly demonstrated on stroboscopy (figure). Treatment options included (1) botulinum injection to the adductor muscles, (2) medialization of the true vocal folds to reduce hyperfunctional compensation for minor glottic insufficiency and related increased closure contact on the arytenoids, (3) excision of the lesion with local mucosal flap coverage, and (4) treatment of the lesion with the pulsed-dye laser.

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Arytenoid cartilage granulomas are the result of chronic mucosal injury. Reflux is a major cause, as is vocal abuse or misuse. Chronic injury to the perichondrium and failure to correct the causative factors can lead to recurrence. All of the previous and proposed treatments described above attempt to address these varied etiologies.

Robert Eller, MD; Mary Hawkshaw, BSN, RN, CORLN; Robert T. Sataloff, MD, DMA

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