Does subepithelial hemorrhage cause persistence of laryngeal granuloma?

Myeloid Phenotypes in Tracheostomy-Associated Granulation Tissue

OBJECTIVE(S)

Tracheostomy-associated granulation tissue is a common, recurrent problem occurring secondary to chronic mucosal irritation. Although granulation tissue is composed of predominantly innate immune cells, the phenotype of monocytes and macrophages in tracheostomy-associated granulation tissue is unknown. This study aims to define the myeloid cell population in granulation tissue secondary to tracheostomy.

METHODS

Granulation tissue biopsies were obtained from 8 patients with tracheostomy secondary to laryngotracheal stenosis. Cell type analysis was performed by flow cytometry and gene expression was measured by quantitative real-time polymerase chain reaction. These methods and immunohistochemistry were used to define the monocyte/macrophage population in granulation tissue and were compared to tracheal autopsy control specimens.

RESULTS

Flow cytometry demonstrated macrophages (CD45+CD11b+) and monocytes (CD45+FSClow SSClow ) represent 23.2 ± 6% of the granulation tissue cell population. The M2 phenotype (CD206) is present in 77 ± 11% of the macrophage population and increased compared to the M1 phenotype (p = 0.012). Classical monocytes (CD45+CD14high CD16low ) were increased in granulation tissue compared to controls (61.2 ± 7% and 30 ± 8.5%, p = 0.038). Eighty-five percent of macrophages expressed pro-inflammatory S100A8/A9 and 36 ± 4% of macrophages co-localized CD169, associated with tissue-resident macrophages. M2 gene expression (Arg1/CD206) was increased in granulation tissue (3.7 ± 0.4, p = 0.035 and 3.5 ± 0.5, p = 0.047) whereas M1 gene expression (CD80/CD86) was similar to controls (p = 0.64, p = 0.3). Immunohistochemistry of granulation tissue demonstrated increased cells co-localizing CD11b and CD206.

CONCLUSIONS

M2 macrophages are the dominant macrophage phenotype in tracheostomy-associated granulation tissue. The role of this cell type in promoting ongoing inflammation warrants future investigation to identify potential treatments for granulation tissue secondary to tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2346-2356, 2023.

Comparison of the Effects of Botulinum Toxin A Injection and Local Glucocorticoid Injection for Treating Laryngeal Contact Granuloma

OBJECTIVES

To compare the effects of botulinum toxin A injection and local glucocorticoid injection for treating laryngeal contact granuloma and to discuss the indications for both regimens.

METHODS

The case data of 50 patients with laryngeal contact granuloma in the outpatient clinic of the Sixth Medical Center of the PLA General Hospital from January 2020 to December 2021 were reviewed, and the patients were divided into the following two groups according to the different treatments received: botulinum toxin A injection or local glucocorticoid injection. Quantitative assessment of the lesion size was performed using Image J software to compare the efficacy in the two groups.

RESULTS

On comparing the cure rate between the two groups at 3 months after treatment, 72% of patients in the botulinum toxin A group were cured compared to 40% of patients in the glucocorticoid group (P = 0.023). On comparing the cure rate between the two groups at 6 months after treatment, 88% of patients in the botulinum toxin A group were cured compared to 64% of patients in the glucocorticoid group (P = 0.047).

CONCLUSIONS

Botulinum toxin A injection is superior to local glucocorticoid injection, and local glucocorticoid injection is more appropriate for patients who cannot tolerate the adverse effects of botulinum toxin A.

Thyroarytenoid botulinum toxin injection for refractory laryngeal contact granuloma

BACKGROUND

Although there are many treatments for laryngeal contact granuloma (LCG), some patients still fail treatment. Botulinum toxin A injection vocal cords may be a salvage therapy.

OBJECTIVES

To study the efficacy of thyroarytenoid botulinum toxin A injection for the treatment of refractory LCG.

MATERIAL AND METHODS

From May 2021 to March 2022, 23 male patients with refractory idiopathic LCG were treated by injection of botulinum toxin A into the thyroarytenoid muscle via the thyrohyoid membrane approach. Inspiratory-phase laryngoscopy images were collected before treatment and 3 months after injection treatment. The lesion size was evaluated with the Farwell granuloma endoscopic grading system and Image J software.

RESULTS

The average age of 23 patients was 49 years. The dose of botulinum toxin injection ranged from 2.5 to 5 units. Three months after injection, 17 patients were cured, 2 patients showed marked improvement, and 4 patients did not experience any effect. The total efficacy rate was 82.61% (19/23), and no serious complications occurred. Almost all patients experienced hoarseness within one week after injection; they gradually recovered after one month, and their voice returned to baseline at 3 months.

CONCLUSIONS

Thyroarytenoid botulinum toxin injection is an effective method for resolving refractory LCG.

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.

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.

Laryngeal Granuloma - Benefit in Treatment with Zinc Supplementation?

Laryngeal granulomas present as contact and postintubation ulcers and granulomas. Essentially, a contact granuloma is a pseudotumor of the lateral wall of the posterior glottis. The most common etiological factor is voice abuse, with predisponing factors such as reflux disease. Postintubation ulcers and granulomas, although of different etiology, according to all the other traits belong to this clinical entity. The therapy of choice is conservative treatment. Surgical laser excision is indicated for resistant cases and those whose size is causing respiratory distress. Treatment of laryngeal granulomas with zinc supplementation is reported in the literature as one of the forms of conservative treatment, and we wanted to consider it in this review. Zinc is an essential mineral that plays a vital role in many biochemical reactions and is considered very important for wound healing.

Retrospective analysis of the clinical course for intubation vs. unspecified laryngeal granulomas

Intubation laryngeal granulomas (ILGs) are a well-known complication of endotracheal intubation. Cases other than ILGs can be categorized as unspecified laryngeal granulomas (ULGs) since their etiologies are often difficult to confirm. We intended to clarify clinical features of both ILGs and ULGs and that anticoagulant medication could cause the formation and delayed healing of ILGs in terms of wound-healing delay. We compared the results of our treatment of ILGs (n = 16) and ULGs (n = 47) treated between 1998 and 2009 to characterize these patients. The clinical course, treatment (medical vs. surgical), indications for surgical resection, treatment outcome, and use of anticoagulants for preexisting disease were reviewed and compared between these two groups. The resolution rate was significantly better in ILGs (p < .05). Five ILGs and seven ULGs were surgically resected. The main reason for resection was airway obstruction and the need for histological assessment, respectively. The use of anticoagulants was significantly higher in ILGs than ULGs (8/16 vs. 4/47, p < .01). The resolution period was significantly longer in the ILGs patients with anticoagulant medication compared to that in the ILGs patients without anticoagulant medication (152 ± 101 days vs. 76 ± 44 days, p < .05). ILGs may have different clinical course from ULGs, especially in terms of the resolution period. Moreover, administration of anticoagulants may deter healing of small injury due to intubation. Patients taking anticoagulants should be managed carefully during the perioperative period to prevent the occurrence of ILGs.

First human model of in vitro Candida albicans persistence within granuloma for the reliable study of host-fungi interactions

Backgound

The balance between human innate immune system and Candida albicans virulence signaling mechanisms ultimately dictates the outcome of fungal invasiveness and its pathology. To better understand the pathophysiology and to identify fungal virulence-associated factors in the context of persistence in humans, complex models are indispensable. Although fungal virulence factors have been extensively studied in vitro and in vivo using different immune cell subsets and cell lines, it is unclear how C. albicans survives inside complex tissue granulomas.

Methodology/Principal Finding

We developed an original model of in vitro human granuloma, reproducing the natural granulomatous response to C. albicans. Persistent granulomas were obtained when the ratio of phagocytes to fungi was high. This in vitro fungal granuloma mimics natural granulomas, with infected macrophages surrounded by helper and cytotoxic T lymphocytes. A small proportion of granulomas exhibited C. albicans hyphae. Histological and time-lapse analysis showed that C. albicans blastoconidia were located within the granulomas before hyphae formation. Using staining techniques, fungal load calculations, as well as confocal and scanning electron microscopy, we describe the kinetics of fungal granuloma formation. We provide the first direct evidence that C. albicans are not eliminated by immunocompetent cells inside in vitro human granulomas. In fact, after an initial candicidal period, the remaining yeast proliferate and persist under very complex immune responses.

Conclusions/Significance

Using an original in vitro model of human fungal granuloma, we herein present the evidence that C. albicans persist and grow into immunocompetent granulomatous structures. These results will guide us towards a better understanding of fungal invasiveness and, henceforth, will also help in the development of better strategies for its control in human physiological conditions.