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Ban MJ, Ryu CH, Woo JH, Lee YC, Lee DK, Kwon M, Hong YT, Lee GJ, Byeon HK, Choi SH, Lee SW. Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force. Clin Exp Otorhinolaryngol 2023; 16:291-307. [PMID: 37905325 DOI: 10.21053/ceo.2023.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.
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Affiliation(s)
- Myung Jin Ban
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Hwan Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Korea
| | - Joo Hyun Woo
- Department of Otorhinolaryngology-Head and Neck Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Young Chan Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Dong Kun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Minsu Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Tae Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Gil Joon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyung Kwon Byeon
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Won Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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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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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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Heyduck A, Pickhard A, Olthoff A, Hoffmann T, Reiter R. [Therapeutic success of proton pump inhibitors in the therapy of contact granulomas]. Laryngorhinootologie 2020; 100:202-206. [PMID: 32557506 DOI: 10.1055/a-1190-4907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
According to the current S2k guideline "Gastroesophageal Reflux Disease (GERD)" of 05/2014, an empirical proton pump inhibitor (PPI) therapy in double standard dose (e. g. Pantoprazole 40 mg 2 ×/day) is recommended for the extraesophageal GERD manifestation (e. g. with formation of a contact granuloma, CG) for 8 weeks. However, valid study data don't exist.In a prospective study from 05.2015 to 12.2019 39 patients consecutively randomized with endoscopically proven KG received PPIs in single (1 × PPI, n = 22) or double standard dose (2 × PPI, n = 17) for 8 weeks. A possible gastrolaryngeal reflux as well as throat sensations, a tendency to clear the throat or a hoarseness were recorded at first presentation and at control after 4 months.This was archieved by videolaryngostroboscopy to detect hoarseness and to assess the development of the granuloma (progression, constant, remission < 50 %, > 50 % or complete). The two groups were compared.The granuloma disappeared or regressed in 40 % of the cases with 1 × PPIs and in 77 % of the cases with 2 × PPIs (p < 0.05) after therapy. At the control appointment 23 % of the patients with 1 × PPIs were completely symptom-free and 77 % of the patients with 2 × PPIs. Throat sensation was the most frequent symptom at first presentation with 64 %. In the control group after PPI therapy in single or double standard dose, throat sensations were only detectable in 33 % and 15 % in case of granuloma remission. However, if the granuloma was persistent, the symptoms could hardly be influenced.The therapy of a KG with PPIs in double standard dose is more effective than in single standard dose. These results must be confirmed on a larger collective.
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Affiliation(s)
- Adrienne Heyduck
- Sektion Phoniatrie und Pädaudiologie der Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Univ.-Klinik Ulm, Ulm, Germany.,Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsmedizin Göttingen, Phoniatrie und Pädaudiologie, Göttingen, Germany
| | - Anja Pickhard
- Hals-Nasen-Ohrenklinik, Technische Universität München, Germany
| | - Arno Olthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsmedizin Göttingen, Phoniatrie und Pädaudiologie, Göttingen, Germany
| | - Thomas Hoffmann
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Univ.-Klinik Ulm, Ulm, Germany
| | - Rudolf Reiter
- Sektion Phoniatrie und Pädaudiologie der Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Univ.-Klinik Ulm, Ulm, Germany
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Martins RHG, Dias NH, Soares CSP, Gramuglia ACJ. Treatment of Laryngeal Granulomas. Int Arch Otorhinolaryngol 2019; 23:e322-e324. [PMID: 31360253 PMCID: PMC6660291 DOI: 10.1055/s-0039-1688456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/17/2019] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Regina Helena Garcia Martins
- Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Universidade Estadual Paulista, Botucatu, São Paulo, SP, Brazil
| | - Norimar Hernandes Dias
- Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Universidade Estadual Paulista, Botucatu, São Paulo, SP, Brazil
| | - Carlos Segundo Paiva Soares
- Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Universidade Estadual Paulista, Botucatu, São Paulo, SP, Brazil
| | - Andrea Cristina Joia Gramuglia
- Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Universidade Estadual Paulista, Botucatu, São Paulo, SP, Brazil
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Rimoli CF, Martins RHG, Catâneo DC, Imamura R, Catâneo AJM. Treatment of post-intubation laryngeal granulomas: systematic review and proportional meta-analysis. Braz J Otorhinolaryngol 2018; 84:781-789. [PMID: 29699879 PMCID: PMC9442835 DOI: 10.1016/j.bjorl.2018.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/08/2018] [Accepted: 03/14/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Laryngeal granulomas post intubation are benign but recurrent lesions. There is no consensus for its treatment. OBJECTIVE To describe the effectiveness of different treatment modalities for primary or recurrent laryngeal granulomas resulting from endotracheal intubation. METHODS Systematic review and proportional meta-analysis. Eligibility criteria - experimental or observational studies with at least five subjects. Outcomes studied - granuloma resolution, recurrence, and time for resolution. Databases used - Pubmed, Embase, Lilacs, and Cochrane. The Stats Direct 3.0.121 program was used. RESULTS Six studies were selected, with 85 patients. The treatments registered were: antireflux therapy, speech therapy, anti-inflammatory drugs, steroids, antibiotics, zinc sulfate and surgery. 85 patients from six studies had primary treatment: surgery±associations (41 patients), resolution chance 75% (95% CI: 0.3-100%, I2=90%), absolute relapse risk 25% (95% CI: 0.2-71%); medical treatment (44 patients), resolution chance 86% (95% CI: 67-97%); and absolute relapse risk 14% (95% CI: 3-33%). There was no significant difference between groups. Three studies, encompassing 19 patients, analyzed secondary treatment (failure or recurrence after primary treatment); three subjects presented new recurrence. The time needed to resolve the lesions varied from immediate, after surgery, to 23 months, for inhaled steroid. CONCLUSION There is no evidence of high quality that proves the efficacy of any treatment for laryngeal granulomas resulting from endotracheal intubation.
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Affiliation(s)
- Caroline Fernandes Rimoli
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Botucatu, SP, Brazil
| | - Regina Helena Garcia Martins
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Botucatu, SP, Brazil.
| | - Daniele Cristina Catâneo
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Departamento de Cirurgia, Botucatu, SP, Brazil
| | - Rui Imamura
- Universidade de São Paulo (USP), Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Antonio José Maria Catâneo
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Departamento de Cirurgia, Botucatu, SP, Brazil
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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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Comparison of the effects of esomeprazole plus mosapride citrate and botulinum toxin A on vocal process granuloma. Am J Otolaryngol 2017; 38:593-597. [PMID: 28655420 DOI: 10.1016/j.amjoto.2017.01.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/16/2017] [Indexed: 02/06/2023]
Abstract
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.
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