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Nonarytenoid laryngeal granulomas.

A 69-year-old woman with dysphonia was taken to the operating room for excision of a left true vocal fold cyst refractory to voice therapy and reflux control. She had previously undergone Nissen fundoplication for severe reflux and inability to tolerate anti-reflux medications. Examination 1 week postoperatively revealed swelling at the excision site on the left vocal fold. She was started on a prednisone taper and a strict low-acid diet. Upon her re-examination 2 weeks later, a large, left true vocal fold granuloma was observed at the operative site, along the middle third of the true vocal fold (figure 1).

The patient subsequently underwent microdirect laryngoscopy, excision of a left true vocal fold granuloma, angiolytic KTP laser treatment of the attachment site, and dexamethasone injection. Two weeks postoperatively, she was doing well with no evidence of recurrent granuloma (figure 2).

Contact granulomas are benign lesions of the larynx that characteristically develop posteriorly at the vocal process of the arytenoid. The most common presenting symptom is hoarseness, with sore throat, dyspnea on exertion, globus, stridor, and "cut-off voice" occurring less commonly. (1)

Contact granulomas result from trauma, often due to laryngopharyngeal reflux, chronic cough, and throat clearing, as well as vocal abuse. They are perpetuated by repeated contact between vocal processes during phonation. (2) This prevents adequate wound healing and leads to ulcer formation with subsequent reactive tissue overgrowth, often presenting as a nodular, reddish lesion. (3) These granulomas, however, lack typical features of granulomatous lesions on light microscopy. Instead, histopathology of contact granulomas includes hyperplastic epithelium, granulation tissue, and chronic inflammatory infiltrate, with no reported cases of malignant transformation. (4,5)

Very rarely, contact and postintubation granulomas are located on the middle third or anterior portion of the vocal folds, with few reported in the literature. The senior author (R.T.S.) has described a case ofbilateral granuloma and varicosity in the midportion of the vocal folds, as well as a laryngeal granuloma of the false vocal fold. (6,7) The natural course and treatment of contact versus postintubation granulomas differ, as contact granulomas have a high likelihood of recurrence (92%) when removed surgically. (8) The mainstay of treatment of contact granulomas is conservative, consisting initially of anti-reflux medication and voice therapy. Surgical removal is reserved primarily for cases refractory to medical treatment or when the diagnosis is in doubt, and "bloodless" in-office techniques such as KTP laser treatment can offer increased accessibility, decreased morbidity, and lower recurrence rates than traditional cold steel microlaryngoscopy techniques, but at the expense of complete histologic evaluation. (9,10)

Marissa Evarts, DO; Jonathan Romak, MD, Robert T. Sataloff, MD, DMA, FACS

From the Department of Otolaryngology and Facial Plastic Surgery, Philadelphia College of Osteopathic Medicine (Dr. Evarts); and the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia (Dr. Evarts, Dr. Romak, and Dr. Sataloff).

References

(1.) Bradley PJ. Arytenoid granuloma. J LaryngolOtol 1997;111(9):801-3.

(2.) Leonard R, Kendall K. Effects of voice therapy on vocal process granuloma: A phonoscopic approach. Am J Otolaryngol 2005;26(2):101-7.

(3.) Bohlender J. Diagnostic and therapeutic pitfalls in benign vocal fold diseases. GMS Curr Top Otorhinolaryngol Head Neck Surg 2013;12 Doc01.doi3205/cto000093.

(4.) Devaney KO, Rinaldo A, Ferlito A. Vocal process granuloma of the larynx--recognition, differential diagnosis and treatment. Oral Oncol 2005;41(7):666-9.

(5.) Heller AJ, Wohl DL. Vocal fold granuloma induced by rigid bronchoscopy. Ear Nose Throat J 1999;78(3):176-8, 180.

(6.) Anderson T, Hawkshaw M, Sataloff RT. Bilateral granuloma and varicosity in the midportion of the vocal folds. Ear Nose Throat J 2002;81(6):374.

(7.) Sataloff RT, Spiegel JR, Hawkshaw MJ. Laryngeal granulomas of the false vocal fold. Ear Nose Throat J 1995;74(10):687.

(8.) Ylitalo R, Lindestad PA. A retrospective study of contact granuloma. Laryngoscope 1999;109(3):433-6.

(9.) Karkos PD, George M, Van Der Veen J, et al. Vocal process granulomas: A systematic review of treatment. Ann Otol Rhinol Laryngol 2014;123(5):314-20.

(10.) Mascarella MA, Young J. In-office excision en masse of a vocal process granuloma using the potassium-titanyl-phosphate laser. J Voice 2016;30(l);93-5.

Caption: Figure 1. Videostroboscopy reveals the left true vocal fold granuloma.

Caption: Figure 2. No evidence of the granuloma is seen 2 weeks after excision and angiolytic KTP laser treatment.
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Title Annotation:LARYNGOSCOPY CLINIC
Author:Evarts, Marissa; Romak, Jonathan; Sataloff, Robert T.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Sep 1, 2018
Words:721
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