Vocal fold granuloma: The "ball-valve" phenomenon.

An 80-year-old woman came to the office with a sudden, profound dysphonia (near-aphonia) that developed following severe coughing spells. Her history was significant for several episodes of hoarseness, which had resolved following surgical excision of benign granulation tissue that had arisen in the right false vocal fold and had prolapsed onto the true vocal fold.

Strobovideolaryngoscopy had recently revealed the presence of a recurrent granuloma of her right false vocal fold. This granuloma was being treated conservatively with oral steroids and antireflux therapy. Laryngoscopy revealed that a large granuloma was obscuring the glottis and both vocal folds. The patient was taken emergently for removal of this mass. A video-print taken prior to the excision revealed the obstructive pyogenic granuloma (figure).

Vocal fold granulomas tend to arise in patients who have a history of vocal abuse, gastric reflux disease, prolonged endotracheal intubation, trauma, or surgery. Although these lesions can be treated medically with antireflux therapy, antibiotics, steroids, voice therapy, and by eliminating other factor(s) that cause chronic irritation, they often require surgical resection. Granulomas can recur, as they did in this patient, requiring multiple excisions. However, these lesions are usually located in the cartilaginous portion of the larynx, near the vocal process. The site of the lesion in this patient is uncommon, and no reason for it could be determined.

The pyogenic granuloma in this patient is of particular interest because the sudden onset of aphonia associated with her coughing spells represents a rare but important cause of airway obstruction. The base of the lesion was located on a narrow pedicle arising from the right false vocal fold, and the mass acted as a "ball valve" occluding the airway. In this type of situation, emergent excision of the lesion is required.

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