Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Contact Granulomas Treatment & Management

  • Author: James D Garnett, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 10, 2016
 

Medical Therapy

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.
Next

Surgical Therapy

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.  A KTP laser may also be used either in the clinic setting or in the operating room.

Previous
Next

Preoperative Details

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
Previous
Next

Intraoperative Details

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 CO2 laser on a low-watt setting (1-3 W), with an adequate thermal relaxation time (0.1-second pulse with 0.5-second interval) to reduce collateral heat injury. For a KTP laser, use 8-10 watts, a 15 ms pulse, and a 2 Hz repetition rate, with a 400 nm bare fiber.

Previous
Next

Postoperative Details

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.
Previous
Next

Follow-up

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.

Previous
Next

Complications

See the list below:

  • 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
Previous
Next

Outcome and Prognosis

Outcome rates include the following:

  • 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

A retrospective study by Lee et al analyzing 590 cases of contact granuloma found that long-term good response rates to various treatments were as follows[5] :

  • Observation: 20.5%
  • Steroid inhalation: 31.6%
  • Proton pump inhibitor use: 44.0%
  • Voice therapy: 44.3%
  • Surgical removal: 60.0%
  • Botulinum toxin injection: 74.2%

It was also found that surgical removal of granulomas was associated with a significantly higher recurrence rate than was observation (37.1% vs 10.3%, respectively).[5]

A study by Jin et al indicated that spontaneous resolution of contact granulomas is more likely in female patients and for granulomas with a narrow base.[6]

Previous
Next

Future and Controversies

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.

Previous
 
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, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

John Schweinfurth, MD 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 Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.

References
  1. Beham AW, Puellmann K, Laird R, Fuchs T, Streich R, Breysach C, et al. A TNF-regulated recombinatorial macrophage immune receptor implicated in granuloma formation in tuberculosis. PLoS Pathog. 2011 Nov. 7(11):e1002375. [Medline]. [Full Text].

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

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

  4. 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. 2009 Aug. 13(8):1422-9. [Medline].

  5. Lee SW, Hong HJ, Choi SH, et al. Comparison of treatment modalities for contact granuloma: a nationwide multicenter study. Laryngoscope. 2014 May. 124 (5):1187-91. [Medline].

  6. Jin YJ, Lee SJ, Lee WY, Jeong WJ, Ahn SH. Prognostic factors for prediction of follow-up outcome of contact granuloma. Eur Arch Otorhinolaryngol. 2014 Jul. 271 (7):1981-5. [Medline].

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

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

  9. 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.

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

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

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

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

 
Previous
Next
 
Left vocal process granuloma on initial presentation (scope view of 70°).
Vocal process granuloma 2 months after initiation of antireflux therapy and speech therapy intervention in a patient who initially presented with left vocal process granuloma (scope view of 70°).
Vocal process granuloma 4 months after initiation of antireflux therapy and speech therapy intervention (scope view of 70°).
Flexible endoscopic view of contact ulcer in a patient upon presentation. The patient underwent surgical resection with recurrence prior to referral.
Resolution of contact granuloma 5 months after intensive antireflux therapy, speech therapy intervention, and botulinum toxin injection into left vocal fold (flexible endoscopic view). Note the small, red, residual spot.
24 hour pharyngeal pH probe study revealing moderate increase in acidity (decrease in pH) below 5.5 during the night.
This patient was evaluated for hoarseness after prolonged intubation. The lesion resolved with observation and proton pump inhibitor therapy. Video courtesy of Vijay R Ramakrishnan, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.