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Yu PJ, Hung WC, Wang CT. Treatment Outcomes of Intralesional Steroid Injection for Refractory Vocal Process Granuloma. Clin Otolaryngol 2024; 49:822-826. [PMID: 39135379 DOI: 10.1111/coa.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 12/25/2023] [Accepted: 07/26/2024] [Indexed: 10/05/2024]
Abstract
OBJECTIVES Vocal process granuloma (VPG) is a chronic condition resulting from a mucoperichondrial injury of vocal process. Initial conservative treatment typically involves vocal hygiene education and antireflux medication. Treatment challenges arise with refractory cases. Outcomes of second-line treatments such as surgical excision and botulinum toxin injections remain inconsistent. Thus, we propose this study to investigate the effectiveness of intralesional steroid injections for refractory VPG. METHODS We conducted a retrospective review of 23 patients with VPG who showed no improvement after 3 months of proton pump inhibitors. These patients underwent one to three courses of monthly in-office intralesional steroid injections as a second-line therapy. Treatment outcomes were evaluated by measuring the size of the VPG relative to the length of the vocal folds before and after the final injection procedure. RESULTS Results showed a significant reduction in VPG size from baseline of 27.74 ± 15.06 to 5.48 ± 8.95 (p < .001). 15 out of 23 patients were responsive (size reduction ≥ 75%) to intralesional steroid injection. Alcohol consumption and longer symptom duration were associated with a poor response (size reduction <75%), whereas prior intubation was associated with better response. CONCLUSIONS For refractory VPG not responding to conservative treatment, intralesional steroid injection appears to be a promising alternative option without significant adverse effects.
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Affiliation(s)
- Po-Jun Yu
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wei-Chen Hung
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chi-Te Wang
- Department of Otolaryngology Head and Neck Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Electrical Engineering, Yuan Ze University, Taoyuan, Taiwan
- Department of Special Education, University of Taipei, Taipei, Taiwan
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Kim BH, Park H, Shin CM, Huh G, Jung YH, Jeong WJ. Prediction of the efficacy of proton-pump inhibitors in patients with contact granuloma using 24-hour combined dual channel pH/impedance monitoring. Auris Nasus Larynx 2024; 51:548-552. [PMID: 38537558 DOI: 10.1016/j.anl.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/05/2024] [Accepted: 02/14/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES We aimed to evaluate the treatment outcomes of proton-pump inhibitors (PPIs) in patients with contact granuloma (CG) and to investigate the parameters of 24 h combined dual channel pH/impedance (24 h pH/MII) monitoring, which are reliable for predicting the response to PPI of CG patients. METHODS We reviewed the medical records of patients with CG who had been treated with PPIs and had completed more than 6 months of follow-up. We classified the patients into two groups (cured vs. persistent), according to their PPI treatment outcomes. Reflux events were categorized into three groups based on pharyngeal pH during reflux: 1) acid reflux (pH < 4), 2) weak acid reflux (4 < pH < 7), and 3) weak alkaline reflux (pH >7), as detected by a proximal probe. We compared the results of 24h-pH/MII between the two groups and used receiver operating characteristic curve (ROC) analysis to determine the cutoff values of significant parameters for predicting responses to PPIs. RESULTS Among 22 patients who completed at least 6 months of PPI treatment and follow-up, weak acid reflux events were more frequently observed in persistent group than in the cured group (p = 0.046), and the proportion of weak acid reflux was also higher in the persistent group (p = 0.031) than in the cured group. Reliable parameters predictive of a poor response to PPIs were a number of weak acid reflux events ≥ 11 (area under the curve [AUC], 0.775; p = 0.03) and a proportion of weak acid reflux events ≥ 56.7 % (AUC, 0.763; p = 0.038) in ROC analyses. CONCLUSION Weak acid reflux was identified as a significant factor associated with the treatment outcomes of PPIs in patients with CG. A number of weak acid reflux events ≥ 11 is considered to be the most reliable predictor of a poor response to PPIs in patients with CG.
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Affiliation(s)
- Bo Hae Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Hanaro Park
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Cheol Min Shin
- Internal Medicine, Seoul National University Bundang Hospital, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Gene Huh
- Department of Otorhinolaryngology-Head and Neck Surgery, St. Vincent's Hospital, Suwon, South Korea
| | - Young Ho Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, Seoul, South Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea; Sensory Organ Research Institute, Seoul National University Medical Research Center, Seoul, South Korea.
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Cruz DRD, Zheng A, Debele T, Larson P, Dion GR, Park YC. Drug delivery systems for wound healing treatment of upper airway injury. Expert Opin Drug Deliv 2024; 21:573-591. [PMID: 38588553 PMCID: PMC11208077 DOI: 10.1080/17425247.2024.2340653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/04/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Endotracheal intubation is a common procedure to maintain an open airway with risks for traumatic injury. Pathological changes resulting from intubation can cause upper airway complications, including vocal fold scarring, laryngotracheal stenosis, and granulomas and present with symptoms such as dysphonia, dysphagia, and dyspnea. Current intubation-related laryngotracheal injury treatment approaches lack standardized guidelines, relying on individual clinician experience, and surgical and medical interventions have limitations and carry risks. AREAS COVERED The clinical and preclinical therapeutics for wound healing in the upper airway are described. This review discusses the current developments on local drug delivery systems in the upper airway utilizing particle-based delivery systems, including nanoparticles and microparticles, and bulk-based delivery systems, encompassing hydrogels and polymer-based approaches. EXPERT OPINION Complex laryngotracheal diseases pose challenges for effective treatment, struggling due to the intricate anatomy, limited access, and recurrence. Symptomatic management often requires invasive surgical procedures or medications that are unable to achieve lasting effects. Recent advances in nanotechnology and biocompatible materials provide potential solutions, enabling precise drug delivery, personalization, and extended treatment efficacy. Combining these technologies could lead to groundbreaking treatments for upper airways diseases, significantly improving patients' quality of life. Research and innovation in this field are crucial for further advancements.
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Affiliation(s)
- Denzel Ryan D. Cruz
- Medical Scientist Training Program, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Avery Zheng
- Chemical Engineering Program, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Tilahun Debele
- Chemical Engineering Program, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Peter Larson
- Department of Otolaryngology – Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory R. Dion
- Department of Otolaryngology – Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Yoonjee C. Park
- Chemical Engineering Program, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, OH, USA
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Boyce C, Schmidt KL, Gilbert MR. Management of Idiopathic Vocal Process Granuloma: A Survey of Academic Laryngologists. Laryngoscope 2024; 134:795-802. [PMID: 37602761 DOI: 10.1002/lary.30976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
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.
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Affiliation(s)
- Claire Boyce
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kelly L Schmidt
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Mark R Gilbert
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
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Teng TZJ, Zhai C, Ng CHL. Vocal Fold Granuloma: Updates and Advancements in Treatment. J Voice 2023:S0892-1997(23)00314-4. [PMID: 37985285 DOI: 10.1016/j.jvoice.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE/HYPOTHESIS Vocal fold granulomas (VFGs) are benign outgrowths from vocal folds with varying etiologies. If untreated, VFGs can result in mass effects on the surrounding larynx, leading to dysphagia, hoarseness of voice, and possibly dyspnea. With new advancements, novel treatment options and innovative collaborations of previous treatment modalities have started to surface. STUDY DESIGN This review aims to provide a world review of the current risks, etiologies, and complications surrounding VFGs, as well as discuss the current and future treatment modalities surrounding VFGs. METHODS Four databases (PubMed, Cochrane Library, Embase, and WoS) were searched from the earliest records until February 2023 using search terms related to VFGs. Relevant articles were assessed and analyzed to provide a broad scope of the current treatment options for VFGs. RESULTS/CONCLUSIONS The treatment options for VFGs run both wide and deep, ranging from conservative voice therapy to laser vaporization to surgical excision. Within each modality, variations to each technique and method of administration also play a role in maximizing the effectiveness of treatment. Overall, with more higher-powered studies, the complex interplay of treatment modalities can be further untangled to determine the ideal combination treatment for various VFGs.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Ministry of Health Holdings, Singapore, Singapore; Department of Otorhinolaryngology-Head and Neck Surgery, Sengkang General Hospital, SingHealth, Singapore, Singapore.
| | - Chenlu Zhai
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Christina Hui Lee Ng
- Department of Otorhinolaryngology-Head and Neck Surgery, Sengkang General Hospital, SingHealth, Singapore, Singapore
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Wang X, Liu Z, Peng L, Zhang J, Liu L, Zhang C, Li J. History of Previous Surgical Resection Promotes the Sclerosis of the Arytenoid Cartilage in Patients With Laryngeal Contact Granuloma. J Voice 2023:S0892-1997(23)00328-4. [PMID: 37951814 DOI: 10.1016/j.jvoice.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To explore the relationship between arytenoid cartilage sclerosis and a history of previous surgical resection in patients with laryngeal contact granuloma. METHODS 167 patients with laryngeal contact granuloma treated from March 2016 to December 2018 were studied. The high-resolution computed tomography (HRCT) data of the sclerosis of arytenoid cartilage is divided into asymmetric sclerosis, bilateral sclerosis, and no sclerosis according to the range of sclerosis. The proportions of various ranges of sclerosis in two subgroups of patients were compared to patients with and without a history of previous surgical resection. RESULTS The arytenoid cartilage sclerosis rate of 167 patients was 69.46%. The exact probability method showed that P < 0.001, suggesting that the distribution of arytenoid cartilage sclerosis was different in patients with and without a history of previous surgical resection, and there was a moderate correlation between the extent of arytenoid sclerosis and history of previous surgical resection (Cramer's V = 0.436, P < 0.001). There were 18 cases of bilateral sclerosis in patients with a history of previous surgical resection, of which 50% had contralateral recurrence after combined therapy (proton pump inhibitor (PPI) and glucocorticoid injection into granuloma via the thyrohyoid membrane approach), accounting for 75% of recurrence after combined therapy. CONCLUSION Surgery promotes the expansion of arytenoid sclerosis, Patients with bilateral arytenoid sclerosis are prone to recurrence of contralateral laryngeal contact granuloma.
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Affiliation(s)
- Xiaoyu Wang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Zhi Liu
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Lili Peng
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Jinhong Zhang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Lianlian Liu
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Chun Zhang
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Jinrang Li
- Department of otolaryngology, The Sixth Medical Center of PLA General Hospital, Beijing, China.
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Woo JH, Oh JH, Lim BW, Kim DY. Treatment Results of Vocal Process Granuloma: Intubation versus Contact Granuloma. Int Arch Otorhinolaryngol 2023; 27:e191-e196. [PMID: 37125377 PMCID: PMC10147457 DOI: 10.1055/s-0043-1768205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/07/2021] [Indexed: 05/02/2023] Open
Abstract
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.
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Affiliation(s)
- Joo Hyun Woo
- Department of Otorhinolaryngology-Head and Neck Surgery, Gachon University College of Medicine, Gil Medical Center, Seongnam, South Korea
- Address for correspondence Joo Hyun Woo, MD, PhD Department of Otorhinolaryngology-Head and Neck Surgery, Gachon University, Gil Medical Center, ENT officeNamdong-daero 774 beon-gil 21, Namdong-gu, Incheon 21565South Korea
| | - Jae Hwan Oh
- Department of Otorhinolaryngology-Head and Neck Surgery, Gachon University College of Medicine, Gil Medical Center, Seongnam, South Korea
| | - Byung Woo Lim
- Department of Otorhinolaryngology-Head and Neck Surgery, Gachon University College of Medicine, Gil Medical Center, Seongnam, South Korea
| | - Dong Young Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Gachon University College of Medicine, Gil Medical Center, Seongnam, South Korea
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McCoul ED, Megwalu UC, Joe S, Gray R, O'Brien DC, Ference EH, Lee VS, Patel PS, Figueroa-Morales MA, Shin JJ, Brenner MJ. Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians. Otolaryngol Head Neck Surg 2023; 168:643-657. [PMID: 35349383 DOI: 10.1177/01945998221087664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/26/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders. DATA SOURCES PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines. REVIEW METHODS A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings. CONCLUSIONS Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss. IMPLICATIONS FOR PRACTICE Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.
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Affiliation(s)
- Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Uchechukwu C Megwalu
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California
| | - Stephanie Joe
- Department of Otolaryngology-Head and Neck Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Raluca Gray
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel C O'Brien
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada
| | - Elisabeth H Ference
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Victoria S Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Prayag S Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Marco A Figueroa-Morales
- Department of Otolaryngology-Head and Neck Surgery, Mexican Social Security Institute, Mexico City, Mexico
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy of anti-reflux therapy on the idiopathic vocal process granulomas. METHOD This was a prospective case series study. The patients with vocal process granulomas who met the inclusion criteria were analysed. Proton pump inhibitors and vocal hygiene education were conducted for 8-20 weeks. RESULTS Of the 16 patients with vocal process granulomas, 5 (31.25 per cent) patients achieved complete remission. The complete remission rate of granulomas was not significantly related to age (p = 1.000), sex (p = 0.296), side (p = 0.299), position (p = 0.100), endoscopic morphology (p = 0.263) or proton pump inhibitor treatment course (p = 0.543) but was significantly associated with granuloma location (p = 0.001) and granuloma size (p = 0.012). CONCLUSION Granulomas in the vocal cord and the margin of the vocal process had an excellent response to proton pump inhibitors, but granulomas on the surface of vocal process and arytenoid cartilage body had little response to proton pump inhibitors. The prolonged period of proton pump inhibitor treatment did not increase the complete remission rate of vocal process granulomas.
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Hollis AN, Ghodke A, Farquhar D, Buckmire RA, Shah RN. Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation. Ann Otol Rhinol Laryngol 2021; 131:1267-1273. [PMID: 34965742 DOI: 10.1177/00034894211065805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. METHODS A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. RESULTS Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT (P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (P = .042) in the multivariate analysis. CONCLUSIONS Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.
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Affiliation(s)
- Alison N Hollis
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ameer Ghodke
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Douglas Farquhar
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Robert A Buckmire
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rupali N Shah
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Chang CWD, McCoul ED, Briggs SE, Guardiani EA, Durand ML, Hadlock TA, Hillel AT, Kattar N, Openshaw PJM, Osazuwa-Peters N, Poetker DM, Shin JJ, Chandrasekhar SS, Bradford CR, Brenner MJ. Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era. Otolaryngol Head Neck Surg 2021; 167:803-820. [PMID: 34874793 DOI: 10.1177/01945998211064275] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. DATA SOURCES PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. REVIEW METHODS Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. CONCLUSIONS Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. IMPLICATIONS FOR PRACTICE SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.
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Affiliation(s)
- C W David Chang
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
| | - Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Selena E Briggs
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University, Washington, DC, USA
| | - Elizabeth A Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Marlene L Durand
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Infectious Disease Service, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Tessa A Hadlock
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nrusheel Kattar
- Department of Surgery, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Comparison of PPI and combined treatment in the treatment of recurrent laryngeal contact granuloma. Am J Otolaryngol 2021; 42:102766. [PMID: 33125906 DOI: 10.1016/j.amjoto.2020.102766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022]
Abstract
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.
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Ho CF, Lee YC, Hsin LJ, Lee LA, Li HY, Fang TJ. Low-Dose LEMG-Guided Botulinum Toxin Type A Injection for Intractable Vocal Process Granulomas. J Voice 2020; 36:277-282. [PMID: 32595029 DOI: 10.1016/j.jvoice.2020.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Vocal process granuloma (VPG) has a varied treatment success rate and may frustrate patients and physicians due to poor outcomes. There is still a lack of standard protocols to manage VPG. This study aimed to review the efficiency of a standardized low-dose laryngeal electromyographic (LEMG)-guided botulinum toxin A (BTA) injection in intractable vocal granulomas. METHODS Twenty-four patients with intractable VPG were recruited. All patients underwent percutaneous LEMG-guided BTA injection on the thyroarytenoid-lateral cricoarytenoid muscle complex in an office setting. The injecting dose was standardized to 1 U in 0.1 mL normal saline at a time. We evaluated the treatment effect by measuring the lesion size with serial laryngoscope evaluations. RESULTS The postinjection follow-up time varied from 3 to 23 months. Twenty-one patients (87.5%) experienced complete regression of the granuloma over 1-7 months (median 3 months). No major adverse effects were noted during the follow-up period. CONCLUSION For recalcitrant VPG, LEMG-guided low-dose BTA injection has the potential to be a safe, efficient, and effective treatment.
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Affiliation(s)
- Che-Fang Ho
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yi-Chan Lee
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Li-Jen Hsin
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Ang Lee
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsueh-Yu Li
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Assessing the utility of non-surgical treatments in the management of vocal process granulomas. The Journal of Laryngology & Otology 2020; 134:68-73. [PMID: 31918788 DOI: 10.1017/s0022215119002524] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Amy L Rutt
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Jacksonville, FL, USA
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The treatment of vocal process granuloma. Am J Otolaryngol 2018; 39:367-368. [PMID: 29398186 DOI: 10.1016/j.amjoto.2018.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/28/2018] [Indexed: 11/22/2022]
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Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis C(CW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg 2018; 158:S1-S42. [DOI: 10.1177/0194599817751030] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Libby J. Smith
- University of Pittsburgh Medical, Pittsburgh, Pennsylvania, USA
| | - Marshall Smith
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Peak Woo
- Icahn School of Medicine at Mt Sinai, New York, New York, USA
| | - Lorraine C. Nnacheta
- Department of Research and Quality, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Surgical Treatment Outcomes of Vocal Process Granuloma After Endotracheal Intubation. J Craniofac Surg 2018; 29:e387-e389. [PMID: 29481512 DOI: 10.1097/scs.0000000000004389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Perkins EL, Basu S, Garcia GJM, Buckmire RA, Shah RN, Kimbell JS. Ideal Particle Sizes for Inhaled Steroids Targeting Vocal Granulomas: Preliminary Study Using Computational Fluid Dynamics. Otolaryngol Head Neck Surg 2017; 158:511-519. [PMID: 29160160 DOI: 10.1177/0194599817742126] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth L Perkins
- 1 Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Saikat Basu
- 1 Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Guilherme J M Garcia
- 2 Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,3 Biotechnology and Bioengineering Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert A Buckmire
- 1 Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rupali N Shah
- 1 Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julia S Kimbell
- 1 Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Ogawa M, Hosokawa K, Iwahashi T, Inohara H. The results of Kaplan-Meier and multivariate analyses of etiological factors related to the outcome of combined pharmacological therapy against laryngeal granuloma. Acta Otolaryngol 2016; 136:1141-1146. [PMID: 27328639 DOI: 10.1080/00016489.2016.1193891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONCLUSIONS The present results indicate that the diagnosis of gastroesophageal reflux disease (GERD) is an independent etiological factor predicting retardation of the resolution of laryngeal granuloma. OBJECTIVES To assess the effects of combined usage of an inhaled corticosteroid plus tranilast and/or a proton pump inhibitor on the size of granulomatous lesions, and to reveal etiological factors related to the outcome using the Kaplan-Meier method and a subsequent multivariate analysis. METHODS Sixty-two patients with laryngeal granuloma were enrolled. An inhaled corticosteroid plus tranilast (300 mg/day) and rabeprazole (20 mg/day) were administered to all of the patients, and only to those diagnosed to have GERD, respectively. The size of granulomatous lesion was measured for each patient at the initial visit and every 4 weeks. At 48 weeks, the Kaplan-Meier plots for lesion disappearance rate were compared between groups with and without each of the etiological factors, followed by Cox proportional-hazards regression. RESULTS The 48-week lesion disappearance rates for the whole population were 82.3%. Although the Kaplan-Meier analysis exhibited significant differences between patients separated by GERD diagnosis, phonotrauma, and habitual smoking, only GERD were identified as a real independent etiological factor affecting the resolution of the lesion by a multivariate analysis using Cox's proportional-hazards regression.
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Abstract
PURPOSE OF REVIEW This article discusses the relationship between inhaled corticosteroids and dysphonia, with discussion of the therapeutic use of inhaled steroids in laryngeal disease and a review of negative laryngeal effects of this class of medication in patients with reactive airway disease. RECENT FINDINGS Although prescribed for their anti-inflammatory effects (predominantly for pulmonary disease and less often for laryngeal conditions), corticosteroid inhalers can cause laryngeal inflammation. This may relate to chemical irritation from the inhaler itself as well as fungal inflammation related to opportunistic candidiasis that may accompany inhaler use. Patients who suffer from dysphonia because of inhaler use may improve if switched to another inhaler. Studies suggest that ciclesonide metered-dose inhaler may have less oropharyngeal deposition and therefore be associated with reduced oropharyngeal candidiasis and dysphonia compared with other inhaled corticosteroids. SUMMARY Corticosteroid inhalers are a common cause of dysphonia and their use should be investigated in any patient with laryngeal complaints.
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Francis DO, Vaezi MF. Should the Reflex Be Reflux? Throat Symptoms and Alternative Explanations. Clin Gastroenterol Hepatol 2015; 13:1560-6. [PMID: 25264272 DOI: 10.1016/j.cgh.2014.08.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/23/2014] [Indexed: 02/07/2023]
Abstract
Although laryngopharyngeal reflux, also known as extraesophageal reflux (EER), was codified more than 25 years ago, it has not been characterized fully. There is no sensitive and specific diagnostic test, and its symptoms often are nonspecific and overlap with those of other conditions commonly seen in primary care and specialist practices. Otolaryngologists have an important role in the evaluation and management of these patients--they must investigate persistent reflux-attributed symptoms by direct visualization of the upper airway and larynx, and, in some circumstances, the esophagus. It is of utmost importance to rule out the possibility of malignancy, which often presents with symptoms similar to those of EER. Once cancer is excluded, many benign upper airway conditions also can masquerade as, and often incorrectly are attributed to, EER. Although reflux is a potential etiologic factor for upper-airway symptoms, it is important not to reflexively blame reflux. We discuss other etiologies that should be considered carefully for persistent symptoms.
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Affiliation(s)
- David O Francis
- Vanderbilt Voice Center, Department of Otolaryngology, Bill Wilkerson Center, Center for Surgical Quality and Outcomes Research, Institute for Medicine and Public Health, Nashville, Tennessee.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Karkos PD, George M, Van Der Veen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol 2014; 123:314-20. [PMID: 24642585 DOI: 10.1177/0003489414525921] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences. DATA SOURCES The data came from a systematic review of the literature. METHODS Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment. RESULTS The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences. CONCLUSIONS There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.
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Affiliation(s)
- Petros D Karkos
- Department of Otolaryngology, Queen Alexandra Hospital, Portsmouth, UK
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Lee SW, Hong HJ, Choi SH, Sun DI, Park YH, Lee BJ, Kwon SK, Park IS, Lee SH, Son YI. Comparison of treatment modalities for contact granuloma: a nationwide multicenter study. Laryngoscope 2013; 124:1187-91. [PMID: 24307485 DOI: 10.1002/lary.24470] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 08/02/2013] [Accepted: 10/10/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study evaluated the efficacy of commonly used treatment modalities and determined predictors of treatment outcome for contact granuloma. STUDY DESIGN Retrospective study. METHODS Twenty otolaryngologists from 18 university hospitals reviewed the medical records of their own contact granuloma patients for the most recent 4 years. To be enrolled as a valid case, each treatment had to continue for at least 3 months. After excluding intubation granuloma, 590 cases of contact granuloma were analyzed. Treatment outcomes were assessed as complete response (CR), marked response (MR), partial response (PR), and no response. The chi-square test was used to compare the efficacy of each treatment modality and logistic regression to determine the predictors of treatment outcome. RESULTS The long-term outcomes of good response (GR) (sum of CR and MR) rates after each treatment were 20.5% for observation, 31.6% for steroid inhalation, 44.0% for proton pump inhibitor (PPI), 44.3% for voice therapy, 60.0% for surgical removal, and 74.2% for botulinum toxin injection. Voice therapy, PPI, and botulinum toxin had more good responses than simple observation for the long-term outcome (P < 0.05). Surgical removal had a significantly higher recurrence rate (37.1%) than simple observation (10.3%) (P < 0.05). CONCLUSIONS Voice therapy or PPI are recommended as first-line treatments. Surgical removal should be reserved for selected patients because of the high chance of recurrence. Botulinum toxin injection can be used not only for primary cases but also for refractory cases with an expected high response rate.
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Affiliation(s)
- Seung Won Lee
- Department of Otolaryngology-Head and Neck Surgery, Soonchunhyang University, Seoul, Republic of Korea
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Hong-Gang D, He-Juan J, Chun-Quan Z, Guo-Kang F. Surgery and proton pump inhibitors for treatment of vocal process granulomas. Eur Arch Otorhinolaryngol 2013; 270:2921-6. [DOI: 10.1007/s00405-013-2527-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/22/2013] [Indexed: 11/30/2022]
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Martins R. Steroid use in laryngeal diseases. Braz J Otorhinolaryngol 2013; 79:132. [PMID: 23670316 PMCID: PMC9443879 DOI: 10.5935/1808-8694.20130025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Song Y, Shi L, Zhao Y, Zhao D, Shi M, Deng Z. Surgical Removal Followed by Radiotherapy for Refractory Vocal Process Granuloma. J Voice 2012; 26:666.e1-5. [DOI: 10.1016/j.jvoice.2011.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 08/05/2011] [Indexed: 10/14/2022]
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Nagai H. Recent research and developmental strategy of anti-asthma drugs. Pharmacol Ther 2011; 133:70-8. [PMID: 21924291 DOI: 10.1016/j.pharmthera.2011.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 08/09/2011] [Indexed: 01/10/2023]
Abstract
Extensive research over the past decade has provided information about the pharmacotherapy of bronchial asthma (BA). Anti-asthma drugs are classified into two categories: relievers (for the relief of asthma attack symptoms) and controllers (for the prevention of asthma symptoms). This paper aims to review the recent advancements of anti-asthma drugs that are controller medicines. The controllers mainly act on immune and inflammatory responses in BA development. 1) Immunomodulators. Drugs that act on the immune response are classified into two categories: immunosuppressors and immunomodulators, including immunopotentiators. The immunomodulation of the Th1 and Th2 imbalance is the first strategy of the controller because allergic BA is thought to be caused by Th2-polarized immunity. Suplatast is a novel immunomodulator that can adjust the imbalance in the Th1/Th2 immune response and shows clear clinical efficacy against BA. The immunomodulator approach has shifted from a more theoretical and conceptual model to one supported by evidence of clinical efficacy.2) Anti-inflammatory agents. Corticosteroids,mast cell stabilizers and autacoid inhibitors are anti-inflammatory agents for BA. The clinical superiority of the combined therapy of inhaled corticosteroids and long-acting beta2 agonists is evident. This combined therapy shows a potent synergic anti-inflammatory effect compared to the effect by corticosteroids alone. Currently, the anti-inflammatory agents for BA under development are drugs affecting lipid mediators. The prostaglandin (PG) D2 antagonist, PGE2, EP3 agonist and PGI2 agonist are being considered in addition to well-established leukotriene and thromboxane A2 inhibitors. New development strategies and therapeutics for controllers are described in this review.
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Affiliation(s)
- Hiroichi Nagai
- Gifu Junior College of Health Science 2-92 higashi-uzura, Gifu 500-8281, Japan.
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