Contact Granulomas Treatment & Management

The primary management of vocal process contact ulcers or granulomas is conservative.

• Cough prevention and treatment

  • If the cough is due to an acute illness or recent instrumentation, a narcotic cough suppressant may become necessary.
  • Chronic cough and throat clearing may be managed by improved hydration, reflux treatment, topical anesthetics, and asthma and allergy treatment as well as other treatments.
• Antireflux treatment

  • Antireflux treatment consists of omeprazole 20-40 mg PO bid (or an equivalent proton pump inhibitor), lansoprazole, or rabeprazole.
  • Ranitidine 300 mg PO bid-qid may be used if proton pump inhibitors are not an option.
• Lifestyle modifications are crucial and must be initiated and maintained even in patients undergoing pharmacotherapy. Instruct patients to implement the following measures:

  • Avoid foods that cause reflux or are acidic (eg, tomato products, pepper, onion, garlic, peppermint).
  • Eliminate intake of caffeine from products such as coffee, sodas, and tea (including green tea).
  • Do not wear tight clothing.
  • Avoid eating 2-3 hours prior to sleep.
  • Elevate the head of the bed.
  • Avoid the use of multiple pillows because they cause a bend at the waist and increase the risk of reflux.
• Speech therapy

  • Speech therapy is essential in all hyperfunctional patients and is also recommended in individuals whose contact ulcer or granuloma may have resulted from intubation trauma or reflux.
  • Speech therapy improves breath support and reduces hard glottal attack.
  • Speech therapy can eliminate poor vocal habits such as throat clearing and straining against a closed glottis.
• Botulinum toxin type A

  • Occasionally, a granuloma that is unresponsive to maximal reflux therapy and good speech therapy is encountered. Botulinum toxin type A is emerging as a treatment option for granulomas that are unresponsive to other therapies.
  • The toxin is administered by injection into the ipsilateral thyroarytenoid muscle.
  • Speech therapy is ongoing during this treatment.
  • The injection is performed either in the clinic or in conjunction with operative resection of the granuloma.
  • The amount injected varies from 2.5-15 U.
  • The goal is paresis or chemical paralysis of the ipsilateral thyroarytenoid or lateral cricoarytenoid muscle to reduce the force of glottal attack and the impact between the 2 vocal processes during phonation and cough.
  • Speech therapy is continued so that the soft glottal attack can be carried over after the effect of the injection wears off in about 3 months.
• Systemic steroid therapy (anecdotal)

  • Doses of steroids stronger than those considered therapeutic have been suggested for the treatment of contact granulomas.
  • Adrenal axis suppression is a concern when using steroids as a treatment option.
  • The use of steroids in the treatment of contact granulomas is not well studied.
  • Topically applied steroids via an inhaler may offer some efficacy.
  • The role of steroids injected directly into the lesion in the office setting is also possible, but population studies are lacking.

Surgical treatment is usually reserved for cases in which other approaches fail, cancer is suspected, the lesion is a fibroepithelial polyp, or the airway is compromised.

Surgery may be frustrating because of the high recurrence rate (37-50%). Surgery may also cause the granuloma to migrate and to follow the wound edge.

If excision or biopsy is performed, use conservative measures to protect the base and the surrounding mucosa. Consider steroid injection into the base of the lesion (triamcinolone acetonide 40 mg/mL).

At the time of surgery, injection of the ipsilateral thyroarytenoid or lateral cricoarytenoid muscles with botulinum toxin type A may be considered. Institute intensive perioperative antireflux therapy.

A further surgical modality that has recently been proposed is the use of a flash lamp pulse dye laser through the side port of a flexible laryngoscope. This procedure is performed in the office setting with topical analgesia. This particular laser interacts preferentially with red pigment, so it cauterizes the feeding vessels to the granuloma without epithelial injury. The long-term efficacy of this technique is not yet known and at this point may be considered investigational.

Prior to surgical intervention, advise the patient of the following options to increase the chance of favorable healing and to decrease the risk of granuloma recurrence.

• Speech therapy to reduce vocally abusive behaviors
• Dietary and behavioral modifications to reduce the incidence of reflux and local laryngeal irritants such as cigarette smoke and acidic foods
• Medical management of reflux
• Preoperative instruction to prepare the patient for the postoperative requirements of voice rest and continued good dietary habits

The precise surgical approach for removal or biopsy of the granuloma is controversial. A major goal is to avoid extending the injury. Some authors advocate subtotal removal to serially shrink the base. Others believe that cold-knife excision with protection of the surrounding mucosa suffices. Because of the vascular nature of a pyogenic granuloma, the laser also is advocated. If used, set the laser on a low-watt (W) setting (1-3 W) with an adequate thermal relaxation time (0.1-second pulse with 0.5-second interval) to reduce collateral heat injury.

After surgery, the patient must observe the following guidelines to allow the wound to heal:

• Rest the voice for 2 weeks; this includes no whispering or throat clearing. Make no audible sounds.
• Continue maximal antireflux therapy, preferably with proton pump inhibitors.
• Practice good dietary habits and avoid caffeine and alcohol.
• Perform video laryngeal stroboscopy at 2 weeks, 4 weeks, and 8 weeks postoperatively to monitor healing and to adjust medical and speech therapy as needed.

Provide follow-up care for the patient on a continuous basis, both for recurrence and for development of associated lesions on the true vocal folds. These associated lesions may occur secondary to similar factors that initiated the development of the granuloma.

• Recurrence
• Migration (especially after surgical therapy)
• Airway obstruction
• Bleeding (usually minor)
• Vocal fold fixation (produced by ankylosis of the cricoarytenoid joint secondary to the inflammatory process)
• A high risk for development of posterior laryngeal stenosis, especially in the presence of bilateral ulcers or granulomas
• Formation of a scar bridge, leading to vocal fold immobility
• Inflammatory process leading to scarring of the interarytenoid muscle or mucosa and resultant contracture of the posterior larynx

• Eighty to 90% of patients whose major risk factor for contact ulcers is vocal abuse respond to speech therapy and medical management.
• Seventy to 80% of patients whose major risk factor for granuloma is reflux respond to medical management.
• Eighty to 100% of patients with postintubation granulomas respond to medical and/or surgical management.
• Recurrence rate with surgical management is 37-50%.
• Reports of the use of botulinum toxin type A have shown a 100% success rate, but the numbers in these studies have been small.

The emerging role for botulinum toxin type A is overwhelming and may hold promise as a first-line therapy in conjunction with antireflux therapy and speech therapy.

The use of topical anti-inflammatory substances, such as mitomycin-C, may hold promise in operative cases, but more investigation is needed to confirm the efficacy of this therapy.

Use of absolute voice rest in the primary treatment of patients with contact ulcers is controversial. Some individuals believe that voice rest gives the larynx the lack of vocal process contact needed for the ulcer to heal. Others have argued that the goal should be to encourage the patient to speak correctly, using proper voice technique. They believe that modified voice rest under observation of a speech therapist helps the ulcer to heal and allows the patient to acquire those vocal habits that may prevent recurrence.

Others fear that absolute voice rest may cause too great a psychological burden, giving the message that silence is good and speaking is bad. Then, when the person speaks, hyperfunction may be exacerbated because the patient holds back and produces voice with inadequate breath support for fear of injury.

An investigational surgical modality is the use of a flash lamp pulse dye laser fiber, or some other laser that interacts with hemoglobin, through a side port of a flexible laryngoscope in the office setting. In the office, the larynx can be visualized using topical anesthesia, a flexible scope, and a bare laser fiber with a conical spread passed through a side channel to the lesion. The laser would ideally interact with the vascular core of the granuloma, leaving epithelium unaffected. The long-term outcome, overall success rate, and complications of this modality are not yet know, but may offer a viable alternative for granulomata that are poorly responsive to more conservative measures.