Surgery and proton pump inhibitors for treatment of vocal process granulomas

Fatal asphyxia due to large laryngeal granuloma

Laryngeal granuloma, vocal process granuloma, or post-intubation granuloma are benign, inflammatory lesions of the arytenoid cartilage vocal process. The etiology of laryngeal granulomas is multifactorial, such as chronic irritation due to endotracheal intubation, vocal cord injury or trauma, and gastroesophageal reflux disease. They can arise postoperatively after mucosal injury due to orotracheal intubation. Clinical manifestations include voice change and dyspnea, which may start one to four months after extubation and may rarely lead to asphyxia. We presented a case of death due to glottic granuloma occurring after a surgical procedure to remove a laryngeal polyp attributed to previous laryngeal injuries by multiple intubations.

Management of Idiopathic Vocal Process Granuloma: A Survey of Academic Laryngologists

OBJECTIVES

Vocal process granulomas (VPGs) are benign laryngeal lesions that may manifest as ulcerated regions of the vocal fold or nodular polypoid lesions. Gold standard treatments for idiopathic VPG are yet to be established at this time. This study evaluated clinical decision-making and outcomes in the treatment of VPG patients based on experiences of academic laryngologists across the United States.

METHODS

A 21-question survey was developed to evaluate each respondent's specific VPG patient population, clinical decision-making in treating VPG, and corresponding treatment outcomes. The survey was distributed to 168 laryngologists at academic institutions across the United States. Data were analyzed through the Qualtrics platform.

RESULTS

A total of 106 responses were analyzed, with a completion rate of 63.1%. Etiology of VPG was most commonly attributed to phonotrauma (96.2%) and reflux (71.8%). Primary first-line treatment was most commonly antireflux medications (92%). Other common first line treatments included voice therapy (58.8%) and inhaled steroids (42.5%). With these treatments, the majority of laryngologists report that recurrence is uncommon (68.4%). Dysphonia was cited as the most frequent long-term sequelae at 27.8%.

CONCLUSIONS

VPG treatment strategies continue to be controversial across the United States with many treatments described in the literature with variable application in the practice of academic laryngologists today. Based on survey results, antireflux medications and voice therapy may be the most widely used and most effective treatment options. Establishment of gold standard therapy for VPG as well as further research into recurrent or persistent VPG despite antireflux and voice therapy should be explored.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:795-802, 2024.

Treatment Results of Vocal Process Granuloma: Intubation versus Contact Granuloma

Introduction  Contact granulomas (CGs) and intubation granulomas (IGs) are known to have different clinical manifestations despite having the same pathological features. Objective  The purpose of the present study was to analyze the treatment results for CG and IG and to obtain clinical information. Methods  We retrospectively reviewed the medical records of patients diagnosed with vocal process granuloma (VPG) between January 2015 and December 2018. The patient's age, sex, medical history, lesion size, lesion type, reflux finding score (RFS), response to treatment, duration of treatment, and follow-up period were compared. Results  Eighteen patients with CG and 14 patients with IG were included in the study. The IG group had more female patients ( p  = 0.0009), showed better response to proton pump inhibitor (PPI) and steroid inhalation (SI) ( p  = 0.036), and had a shorter treatment period ( p  = 0.0029) than the CG group. Five patients who received botulinum toxin injections in their vocal cords had complete remission. Conclusion  Compared with CG, IG was more responsive to treatment with PPI and SI and required a shorter duration of treatment.

Radiofrequency ablation of intubation granulomas

OBJECTIVE

We explored the outcomes and voice parameters of patients undergoing plasma radiofrequency (RF) ablation to treat intubation granulomas.

STUDY DESIGN

Prospective case series.

METHODS AND MATERIALS

Patients with intubation granulomas who met the inclusion criteria underwent RF ablation. The complete remission rate and voice function were evaluated preoperatively and at 6 months postoperatively.

RESULTS

We enrolled 13 patients with 25 intubation granulomas. The mean time between intubation and initial diagnosis was 38.6 days and that between intubation and surgical diagnosis was 2.7 months. All 25 granulomas were successfully removed and histologically confirmed. No surgical remnant was evident on the vocal folds and complete glottal closure was observed at 2 weeks postoperatively. No recurrence or RF ablation-related complications were observed during the 6-month follow-up. The complete remission rate was 100% (13/13). In addition, the mean hoarseness, roughness, breathiness, asthenia, and strain (GRBAS) scores, and the maximum phonation time (MPT), improved significantly after treatment (all P < 0.05).

CONCLUSIONS

RF ablation is effective and safe for patients with intubation granulomas who failed medical management or request the procedure. In this study, the complete resolution rate was high and voice restoration outcomes were good.

[The effect of surgical resection on the treatment of idiopathic laryngeal contact granuloma]

Objective:The aim of this study is to investigate the effect of surgical resection of idiopathic laryngeal contact granuloma on the follow-up treatment. Methods:From April 2014 to December 2019, the clinical data of 390 male patients with idiopathic laryngeal granuloma treated were analyzed retrospectively. The patients were divided into the group with history of surgical resection （172 patients） and the group without surgical resection history （218 patients）, and then both received the combined therapy. The treatment efficacy of the two groups were compared. Results:By the end of 6 months after beginning the combined therapy, the total efficacy rate of the patients with a history of surgery was 71.5%（123/172）, and that in patients without a history of surgery was 97.7% （213/218）. The difference between the two groups was statistically significant（Z=-7.828, P=0.0001）. Among the cured patients, the cure time of patients without the surgery history was shorter than patients with surgery history（Z=-4.441, P=0.0001）. Conclusion:Surgical treatment of laryngeal contact granuloma increases the difficulty of follow-up treatment, so surgical treatment is not recommended for newly diagnosed patients with laryngeal contact granuloma.

A Case of Laryngeal Granulomas After Oral and Maxillofacial Surgery With Prolonged Intubation

Laryngeal granuloma development can be a postoperative complication of laryngeal trauma or irritation resulting from general anesthesia and endotracheal intubation. These rare benign lesions are located primarily over the cartilaginous portions of the larynx, particularly the vocal processes of the arytenoids. Airway manipulation during the intubation process and prolonged intubation periods can be contributing factors to intubation-related laryngeal granulomas, which may manifest 1 to 4 months after intubation. The patient in this case was a female who returned with complaints of throat pain without hoarseness or sensations of a "lump in her throat" 3 months following surgery, during which she was intubated with a 7.0-mm nasotracheal tube for 30 hours, likely contributing to her bilateral laryngeal granulomas. The patient underwent successful conservative medical management consisting of a proton pump inhibitor and an inhaled corticosteroid.

Short-term outcome of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females

OBJECTIVE

To evaluate the short-term efficacy of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females.

METHODS

A total of 14 female patients with laryngeal contact granuloma treated in our outpatient department from November 2017 to January 2020 were included in the study. Inspiratory-phase laryngoscopy images were collected before treatment and 1 month after each injection, and the lesion size was measured and evaluated with ImageJ software.

RESULTS

Two patients achieved complete remission after one injection, with a percent reduction of 100%. After two injections, 4 patients achieved complete remission, with a percent reduction ranging from 96% to 100%. After 3 injections, 4 patients achieved complete remission (including one patient with bilateral lesions), and the percent reduction ranged from 95% to 100%. Three patients achieved incomplete remission, with a percent reduction of 46%, 55%, and 81%, respectively. In one case, there was no remission, and the granuloma increased in size after treatment.

CONCLUSION

In women with laryngeal contact granuloma, transcutaneous glucocorticoid injection therapy can quickly resolve the granuloma in a short period.

Comparison of PPI and combined treatment in the treatment of recurrent laryngeal contact granuloma

OBJECTIVE

To compare the therapeutic effect of PPI and combined treatment in the treatment of patients with recurrent laryngeal contact granuloma.

METHODS

The clinical data of 299 patients with recurrent laryngeal contact granuloma treated with PPI or combined treatment (PPI with glucocorticoid injection into granuloma by the thyroglossal approach) from February 2013 to June 2019 were analyzed retrospectively. Patients were divided into two subgroups: PPI and combined treatment. The cure rates, recurrence rates and cure time of the two subgroups were compared and analyzed separately. Than we can get the optimal treatment of the two treatment in the treatment of recurrent patients.

RESULTS

In recurrent patients, the cure rate (81.20%) and recurrence rate (3%) of combined treatment were superior to those of PPI (57.58%) and recurrence rate (12.12%); (P < 0.05). The cure time of PPI was longer than that of combination therapy (P < 0.001).

CONCLUSION

The therapeutic effect of combined treatment is better than that of PPI in patients with recurrence. At the same time, combined treatment is an effective treatment for recurrent granuloma and can be used as a first-line treatment for recurrent laryngeal contact granuloma.

Assessing the utility of non-surgical treatments in the management of vocal process granulomas

OBJECTIVE

To determine whether patients would have equivalent or improved outcomes when receiving non-surgical management versus surgical removal for vocal process granulomas.

METHODS

A chart review was performed for 53 adults with vocal process granulomas. All patients received baseline anti-reflux treatment consisting of twice-daily proton pump inhibitors and vocal hygiene education. Further treatment approaches were divided into non-surgical (i.e. inhaled corticosteroids, voice therapy, botulinum toxin injections) and surgical groups. Subjective parameters (Voice Handicap Index 10 and Reflux Symptom Index) and outcomes were tabulated and statistically compared. Cause of granuloma was also analysed to determine if this influenced outcomes.

RESULTS

Of 53 patients, 47 (89 per cent) experienced reduction in granuloma size, while 37 (70 per cent) experienced complete resolution. The rate of complete granuloma resolution after initial treatment strategy alone was significantly higher in non-surgical compared to surgical patients (67 and 30 per cent, respectively; p = 0.039). No difference in outcome was seen between iatrogenic and idiopathic granulomas.

CONCLUSION

Non-surgical patients were more likely to experience initial treatment success than those who underwent surgical removal. Continued emphasis should be placed on conservative treatment options prior to surgery for patients with this condition.

Operative and Conservative Management of Laryngeal Contact Granuloma: A Network Analysis and Systematic Review

OBJECTIVE

Laryngeal contact granuloma is a disease of benign hypertrophic granulation tissue at the medial side of vocal process. Numerous studies of conservative and surgical management have reported effectiveness, yet optimal treatment has not been standardized. We compared primary and secondary outcomes of conservative and surgical treatment using endoscopic grading, Voice Handicap Index-10 (VHI-10), maximum phonation time (MPT), and recurrence rate.

METHODS

We performed literature searches of MEDLINE, PubMed, and EMBASE from November 1985 to October 2017, with randomized controlled trials and case control studies of at least three months follow-up as the inclusion criteria. Outcomes included laryngoscopic findings, MPT, and VHI-10. Data regarding study design, outcome analysis, follow-up time, and disease remission were systematically collected.

RESULTS

A total of 1069 patients were abstracted from 19 papers. With conservative treatment, 98% of patients' laryngeal granuloma resolved within three months, and 84% for the surgical group. There was a decrease in VHI-10 of 2.69 (95% credible interval (CI) -9.52 to 3.82) and 6.48 (95% CI -15.00 to 1.94) for conservative and surgical management, respectively. MPT improvement was 1.27 s (95% CI: 2.03-5.84) for conservative treatment and 5.02 s (95% CI: 0.78-8.07) for surgical. For all 19 studies, absolute recurrence risk for control, conservative, and surgical measures were respectively 4%, 16%, and 29%.

CONCLUSIONS

Most patients treated conservatively or surgically alone responded to treatment, but conservative management was favored. VHI-10 and MPT improvement in surgical patients were noted, but only the latter was statistically significant. In regard to recurrence, conservative management had better outcome than surgical. Taken together, the results suggest that minimally symptomatic granulomas have higher response rate and lower recurrence risk when treated conservatively, while larger, symptomatic granulomas may favor surgical excision followed by medical management to reduce risk of recurrence.

Laryngeal granuloma occurring after surgery for laryngeal cancer treated by surgical removal and immediate post-operative radiotherapy: A case report

RATIONAL

Laryngeal granulomas are benign lesion that rarely occurs after surgery of laryngeal cancer. Until now there has not been standard treatment for it.

PATIENT CONCERN

The patient was diagnosed with laryngeal neoplasm one and half a month ago. Endoscopic low-temperature plasma knife in the radical excision of left vocal cord was performed under the general anesthesia. Postoperative histopathological examination confirmed left vocal cord tumor was highly differentiated invasive squamous cell carcinoma (SCC). Then the patient suffered unexplained intermittent dyspnea which persisted nearly 1 month after the surgery. Laryngoscope examination showed granulation formation on the glottis.

DIAGNOSES

The patient was diagnosed with laryngeal granuloma 1 month after the surgery of laryngeal cancer.

INTERVENTIONS

The patient received resection of the laryngeal mass, and pathological examination confirmed the granuloma. Postoperative radiotherapy (RT) was performed within 24 hours after surgery.

OUTCOMES

The patient was followed up for 3 years after surgery and the laryngeal granuloma and laryngeal cancer did not recur during follow-up. The symptoms of intermittent dyspnea disappeared and a satisfactory outcome was achieved.

LESSONS

Usually for primary laryngeal granulomas, surgical treatment alone is not enough, because it is easy to relapse. RT within 24 hours after operation can significantly reduce the recurrence of laryngeal granuloma.

Treatment of Laryngeal Granulomas

Introduction  Laryngeal granulomas are benign, recurrent lesions of many causes (reflux, voice abuse, intubation, and idiopathic), which renders its treatment difficult.

Objective  To describe our experience in the treatment of laryngeal granulomas.

Methods  From 16 medical records of the patients with laryngeal granulomas seen between 2010 and 2017 in a university hospital, the following data were analyzed: age, gender, vocal and gastroesophageal symptoms, vocal overuse, intubation, treatments, videolaryngoscopy before and after the treatment.

Results  Gender: female, 10; male, 6. Age: between 20 and 60 years old (11). Etiology of the granulomas: intubation (9), reflux (4), idiopathic (3). The initial treatments adopted in all cases were: inhaled beclomethasone dipropionate 100 µg 12/12 hours (1 month), proton pump inhibitor, omeprazole 40 mg/day (2 months), and dietary and voice education. After this period, 10 patients (7 postintubation, 3 idiopathic) were submitted to surgery, since no improvements in the symptoms or in the lesions were seen. Of these, two recurred, requiring a second surgery, one of which recurred six times and received botulinum toxin A. Only one patient with granulomas due to laryngopharyngeal reflux presented no improvement in the symptoms nor in the lesion after the pharmacological treatment and had been submitted to microsurgery. All of the other patients with reflux granulomas were successfully treated with the drug treatment, and the longest treatment time for complete remission of the symptoms and of the lesions was 9 months.

Conclusions  In laryngeal granulomas caused by reflux, treatment with inhaled steroids and proton pump inhibitors proved to be effective, although prolonged. In postintubation and idiopathic granulomas, surgery was the best treatment.

Vocal fold granulomas in six brachycephalic dogs: clinical, macroscopical and histological features

Vocal cord granulomas are rarely observed in brachycephalic breeds but often reported in humans as contact granulomas. Six French bulldogs were included in this retrospective descriptive study. Endoscopic laryngeal examinations were performed on all dogs under general anaesthesia. Vocal cord lesions were exclusively unilateral, exophytic, approximately 3-mm wide ulcerated mucosal nodules, arising from the vocal cord. Histopathological examination mainly revealed chronic inflammatory changes on the laryngeal epithelium which were consistent with laryngeal granulomas described in humans, except for the location: vocal cord in dogs versus vocal process in humans. In humans, granulomas result from chronic physical or chemical insult to laryngeal mucosa (chronic cough or throat clearing, vocal abuse, gastro-esophageal reflux). In brachycephalic breeds, chronic inspiratory efforts and air turbulences and gastro-esophageal reflux are suspected to result in chronic laryngeal inflammation.

Surgical Treatment Outcomes of Vocal Process Granuloma After Endotracheal Intubation

INTRODUCTION

The objective of this study was to review the clinical characteristics and surgical treatment outcomes of the vocal process granuloma after the endotracheal intubation.

METHODS

A retrospective chart review was performed at Chonnam National University Hwasun Hospital from January 2008 to December 2015.

RESULTS

Twenty-one vocal process granulomas after endotracheal intubation were diagnosed in 13 patients. The most common symptom was hoarseness. Among 13 patients, bilateral vocal process granulomas were in 8 patients. For the remaining 5 patients, their unilateral vocal process granulomas were all left-sided. All the cases of vocal process granulomas after the endotracheal intubation were treated by laryngoscope microsurgery under general anesthesia. Recurrence of vocal process granulomas was identified in 1 lesion.

CONCLUSION

This study suggests that surgery for vocal process granuloma after endotracheal intubation is a good treatment option for a rapid resolution of lesions and the associated symptoms, along with having low recurrence rates.

Ideal Particle Sizes for Inhaled Steroids Targeting Vocal Granulomas: Preliminary Study Using Computational Fluid Dynamics

Objectives Vocal fold granulomas are benign lesions of the larynx commonly caused by gastroesophageal reflux, intubation, and phonotrauma. Current medical therapy includes inhaled corticosteroids to target inflammation that leads to granuloma formation. Particle sizes of commonly prescribed inhalers range over 1 to 4 µm. The study objective was to use computational fluid dynamics to investigate deposition patterns over a range of particle sizes of inhaled corticosteroids targeting the larynx and vocal fold granulomas. Study Design Retrospective, case-specific computational study. Setting Tertiary academic center. Subjects/Methods A 3-dimensional anatomically realistic computational model of a normal adult airway from mouth to trachea was constructed from 3 computed tomography scans. Virtual granulomas of varying sizes and positions along the vocal fold were incorporated into the base model. Assuming steady-state, inspiratory, turbulent airflow at 30 L/min, computational fluid dynamics was used to simulate respiratory transport and deposition of inhaled corticosteroid particles ranging over 1 to 20 µm. Results Laryngeal deposition in the base model peaked for particle sizes 8 to 10 µm (2.8%-3.5%). Ideal sizes ranged over 6 to 10, 7 to 13, and 7 to 14 µm for small, medium, and large granuloma sizes, respectively. Glottic deposition was maximal at 10.8% for 9-µm-sized particles for the large posterior granuloma, 3 times the normal model (3.5%). Conclusion As the virtual granuloma size increased and the location became more posterior, glottic deposition and ideal particle size generally increased. This preliminary study suggests that inhalers with larger particle sizes, such as fluticasone propionate dry-powder inhaler, may improve laryngeal drug deposition. Most commercially available inhalers have smaller particles than suggested here.

Comparison of the effects of esomeprazole plus mosapride citrate and botulinum toxin A on vocal process granuloma

OBJECTIVES

Vocal process granulomas have a high tendency for persistence despite many treatment alternatives. Anti-reflux medications or botulinum toxin A injections are the main current therapies. There are no studies that compare the effects on vocal process granuloma of proton pump inhibitors plus prokinetic agents with botulinum toxin A injections.

STUDY DESIGN

Prospective cohort study.

METHODS

Adult patients reporting to our outpatient department complaining of trachyphonia and/or abnormal pharyngeal sensations who were found to have contact granulomas. Patients were divided into two groups according to the treatment: esomeprazole with mosapride citrate (n=26) or botulinum toxin A injection (n=20). The reflux symptom index and reflux finding score determined by electronic fibrolaryngoscopy were utilized to assess efficacy.

RESULTS

Forty-six patients were recruited (43 male; 3 female). The mean age (range) was 48.3years (38-69) and the body mass index was 23.51kg/m² (19.13-27.89). Laryngopharyngeal reflux disease diagnosed by RSI or RFS was found in 18 and 27 patients, respectively, and 18 diagnosed without laryngopharyneal reflux disease. Twenty patients (95%) were cured in the esomeprazole with mosapride citrate group and nine (45%) in the botulinum toxin A group. Eleven (55%) patients had recurrence after botulinum toxin A injection, with an average interval of 3.1months (range 1-6). The recorded symptoms after therapy resolved within 6months with a statistically significant improvement in the esomeprazole with mosapride citrate group.

CONCLUSIONS

Combined proton pump inhibitor plus prokinetic drug therapy plays a significant role in the treatment of vocal process granulomas or after surgery.

CT Study of the Arytenoid Cartilage in Patients with Laryngeal Contact Granuloma

Objective

To explore high-resolution computed tomography (HRCT) characteristics of arytenoid cartilage in patients with laryngeal contact granuloma (LCG).

Setting

Tertiary hospitals.

Study Design

Individual case-control study.

Methods

HRCT scans were obtained before treatment from 42 patients with LCG. Similar scans were obtained from 50 patients with glottic laryngeal cancer or vocal cord leukoplakia without vocal process involvement.

Results

Forty-two male patients with LCG were enrolled in the study. There were 41 patients with unilateral vocal cord lesions, and 1 patient had bilateral lesions. All 50 eligible patients in the laryngeal lesion group were men. There were 39 patients with unilateral lesions, and 11 had bilateral lesions. The rate of arytenoid cartilage sclerosis in the LCG group was 79.07% (34/43) on the lesion side and 7.32% (3/41) on the healthy side. In the laryngeal lesion group, the rate of arytenoid cartilage sclerosis was 13.11% (8/61) on the lesion side and 2.56% (1/39) on the healthy side. The rate of arytenoid cartilage sclerosis on the lesion side of patients with LCG was significantly higher than on the healthy side of patients with LCG and significantly higher than both the healthy and lesion sides of patients with laryngeal lesions ( P < .001).

Conclusions

Arytenoid cartilage sclerosis was observed on the lesion side in most patients with LCG, and the presence of sclerosis may support the diagnosis of LCG.

A Case Report of Female Patient with Laryngeal Granuloma

The aim of this case report is to present the laryngeal granuloma in 23 year old female patient. Case outline: The 23 year old female was admitted for examination, because of long lasting, progressive hoarseness. In anamnesis, we found that she has undergone general anesthesia for 8 times, in the early childhood. We performing direct laryngoscopy with complete otorhinolaryngologic examination, rigid endovideostroboscopy and the large granuloma of the larynx was found. Conclusions: Laryngeal granuloma of vocal cords affected mainly men, except for cases associated with laryngeal intubation. We should keep in mind that postintubation laryngeal granuloma might develop after tracheal intubation, so care must be taken to avoid the potential complication.

Analysis of therapeutic methods for treating vocal process granulomas

CONCLUSION

The combination of laryngeal microsurgery and local injections of botulinum toxin type A (BTA) can increase the cure rate of patients with vocal process granulomas (VPGs).

OBJECTIVE

To analyze the therapeutic effects of conservative treatments, microsurgical resection with suturing and microsurgery in combination with local injections of BTA for the treatment of VPGs.

METHODS

A retrospective analysis of 168 cases of VPG was performed. All of the patients initially received a conservative treatment. Some of the patients who did not respond to the conservative treatments were treated using microsurgical resection and microsuturing using an 8-0 absorbable filament. Other patients additionally received a four-point injection of BTA into the thyroarytenoid muscle and the arytenoid muscle on the operated side.

RESULTS

The lesions of 41.3% (71/168) of the patients who were given the conservative treatments (including acid suppression, vocal rest, and voice therapy) disappeared, and the lesions of 10.7% (18/168) of the patients were reduced. The conservative treatments were unsuccessful for 47% (79/168) of the patients. The cure rate was 78.4% (29/37) for the patients who were treated by microscope resection using a CO2 laser and microsuturing of the surrounding mucosa. Of the eight patients who experienced a recurrence, five of them had lesions that disappeared after 3 months of conservative treatment, whereas the other three patients recovered after a second operation. The cure rate of the 42 patients who were treated using microsurgery combined with local injections of BTA was 95.2% (40/42), with only 2 cases of recurrence at 2 months post-treatment.

Prognostic factors for prediction of follow-up outcome of contact granuloma

Although the frequent spontaneous resolution of contact granuloma is reported, the prognostic factor that can predict the possibility of resolution is not clear. We retrospectively analyzed the hospital records and laryngoscopic photos of 52 patients who were diagnosed with contact granuloma between May 2003 and June 2012. The reflux finding score and the shape of the granuloma were analyzed based on the initial laryngoscopy images; additionally, age, gender, chief complaint, and the side afflicted were also analyzed. Of the 52 patients, 40 who were treated conservatively were analyzed. Their mean age was 57.6 years and the mean follow-up period was 28.6 weeks. There was male predominance (87.5%), and the left side was more commonly afflicted (60.0%). Factors significantly associated with resolution included width/height ratio (P = 0.012) and gender (P = 0.048), but not reflux finding score (P = 0.713) or etiology (P = 0.382). So with this data, resolution of contact granuloma is highly probable in cases where the granuloma has a narrow base and the gender is female.