eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Contact Granulomas: Workup

Author: James D Garnett, MD, Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
Contributor Information and Disclosures

Updated: Aug 31, 2009

Workup

Other Tests

  • Double-pH probe (24 h)
    • This test is performed to determine whether reflux is the cause or merely a contributing factor in the formation or propagation of the contact ulcer.
    • The test can also evaluate the efficacy of treatment.
    • Proton pump inhibitor resistance has been reported.
    • The test may help select those who will benefit from Nissen fundoplication.
  • Pharyngeal pH probe (24 h)3
    • This is a newer technology that allows direct measurement of pharyngeal pH.
    • A single channel probe is placed at about the level of the distal tip of the uvula.
    • This allows for direct measurement of acidity, as well as timing of acidity, to help with appropriate therapy.

Diagnostic Procedures

  • Flexible nasopharyngoscopy
    • Always perform visualization of the larynx with a mirror, flexible, or rigid scope. Evidence of laryngeal hyperfunction, muscular tension, and reflux disease may be found, and treatment progress can be followed.
    • The flexible scope allows evaluation of the dynamic activity of the larynx without the distortion of the supraglottic structures that occurs when the tongue is pulled anteriorly during a mirror and rigid telescopic examination.
  • Disadvantages of the flexible scope
    • Reduced detail resolution compared to the mirror or rigid scope
    • Red bias of the flexible scope's color scale
    • Fish-eye distortion of structures
    • Newer "chip-end" flexible scopes offer excellent resolution without the above disadvantages, but the scope can be quite costly and require a specially camera processor to be coupled with a monitor.
  • Videostrobolaryngoscopy
    • The vocal folds vibrate at about 250 hertz (Hz) while phonating a middle C note. The stroboscopic light captures different points on consecutive cycles of phonation, allowing a visual slow-motion study of the larynx in action.
    • The examination is captured on videotape or computer disc for review and study. Subtle, but important, abnormalities that are missed under ordinary light can be observed.
    • The examinations are catalogued and can be reviewed or recalled for future comparison to monitor treatment success or disease progress.
    • This procedure can be performed with both rigid and flexible scopes.
  • Objective voice measurements
    • Allows objective data regarding vocal pitch and perturbation parameters
    • Helps assess treatment results and confirms perceived changes
    • May allow modification of therapy based on parameters in patients who are not responding to the current regimen
    • Noninvasive
  • Electromyography
    • Useful to confirm vocal fold paresis as a predisposing factor toward laryngeal hyperfunction
    • Crucial aid in the instillation of botulinum toxin
  • Speech therapy evaluation
    • Evaluation provides thorough assessment of the vocally abusive behaviors of the patient that contribute to the formation and propagation of the contact ulcer.
    • Factors such as poor breath support, hard glottal attack, improper pitch placement, and other functional issues may be elucidated, thereby facilitating recommendations of proper treatment strategies.
  • If the lesion appears irregular or suspicious for carcinoma in any way, perform a diagnostic laryngoscopy with biopsy.

Histologic Findings

Contact ulcers resemble pyogenic granulomas. Primarily, the ulcers consist of granulation tissue with edema and chronic inflammatory infiltration, neovascularization, and fibrosis covered by squamous epithelium or an ulcerated surface.

More on Contact Granulomas

Overview: Contact Granulomas
Workup: Contact Granulomas
Treatment: Contact Granulomas
Follow-up: Contact Granulomas
Multimedia: Contact Granulomas
References
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References

  1. Jackson C. Contact ulcer of the larynx. Ann Otol Rhinol Laryngol. 1928;37:227-30.

  2. Jackson C, Jackson CL. Contact ulcer of the larynx. Arch Otolaryngol. 1935;22:1-15.

  3. Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. Aug 2009;13(8):1422-9. [Medline].

  4. Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52. [Medline].

  5. de Lima Pontes PA, De Biase NG, Gadelha EC. Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope. Feb 1999;109(2 Pt 1):289-94. [Medline].

  6. Gould WJ, Rubin JS, Yanagisawa E. Benign vocal fold pathology through the eyes of the laryngologist. In: Rubin JS, ed. Diagnosis and Treatment of Voice Disorders. New York, NY:. Igaku-Shoin;1995:146-9.

  7. Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas. Laryngoscope. Feb 1999;109(2 Pt 1):301-6. [Medline].

  8. Nasri S, Sercarz JA, McAlpin T, Berke GS. Treatment of vocal fold granuloma using botulinum toxin type A. Laryngoscope. Jun 1995;105(6):585-8. [Medline].

  9. Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3. [Medline].

  10. Wenig BM, Heffner DK. Contact ulcers of the larynx. A reacquaintance with the pathology of an often underdiagnosed entity. Arch Pathol Lab Med. Aug 1990;114(8):825-8. [Medline].

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Further Reading

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Keywords

contact granulomas, granulomas, contact granuloma, granuloma, vocal cord granuloma, contact pachydermia, pyogenic granuloma, contact ulcer, contact ulcers, vocal process granuloma, larynx

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Contributor Information and Disclosures

Author

James D Garnett, MD, Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
James D Garnett, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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