Vocal process granuloma.

A 44-year-old nurse educator developed progressive hoarseness and vocal fatigue. He had experienced intermittent hoarseness for years, and his symptoms would worsen after long speaking engagements. He also complained of nocturnal cough and wheezing, as well as postnasal drip. Several months earlier, his primary care physician had started him on a proton-pump inhibitor twice daily.

Laryngoscopy identified a bilobed right vocal process granuloma, poor glottic closure, and bilateral stiffness (figure).

[FIGURES A-B OMITTED]

This patient did well following more aggressive reflux therapy (a proton-pump inhibitor four times daily and ranitidine at night), surgical resection of the granuloma, and pulsed-dye laser for recurrence. He is free of granuloma, has good glottic closure, and his voice is normal.

Vocal process granulomas are caused by mucosal trauma, usually in the presence of reflux. Once the process has begun, the granuloma may hold the vocal folds apart; this requires that the patient use more force to phonate, which in turn causes even more trauma. A space-occupying granuloma at the vocal process can cause anterior glottic insufficiency; conversely, a granuloma may be caused by forceful compensation for glottic insufficiency secondary to paresis, vocal fold stiffness, or a combination of both.

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

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