Contact Granulomas Workup

  • Author: James D Garnett, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 13, 2012
 

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)[4]
    • 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.
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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.
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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.

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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.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, 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 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, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Additional Contributors

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. Nov 2011;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. Aug 2009;13(8):1422-9. [Medline].

  5. 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].

  6. 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].

  7. 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.

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

  9. 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].

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

  11. 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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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.
 
 
 
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