Contact Granulomas 

Updated: May 15, 2018
Author: James D Garnett, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Contact granulomas are benign lesions usually located on the posterior third of the vocal fold, which corresponds to the vocal process of the arytenoid cartilage. Contact granulomas may occur unilaterally or bilaterally.

Granulomas of the larynx can be classified into 2 general groups: specific granulomas and nonspecific granulomas. Specific granulomas are rare and include granulomas caused by tuberculosis[1] and syphilis. Nonspecific granulomas are benign and are unilaterally or bilaterally located on the vocal processes of the vocal folds. Histologically, they resemble pyogenic granulomas.

See the image below.

Left vocal process granuloma on initial presentati Left vocal process granuloma on initial presentation (scope view of 70°).

Contact ulcers (or granulomas) historically were thought to be the result of voice abuse or misuse, and the granulomas of intubation or gastroesophageal reflux were separate subsets of these conditions. However, for all purposes, the appearance, symptomatology, and treatment of these nonspecific granulomas are identical; therefore, both subsets of nonspecific granulomas can be considered a single entity.

Chevalier Jackson first identified contact ulcers in 1928.[2] He collected 127 case reports dating to 1888. In 1935, Jackson and Jackson suggested a mechanical cause related to the hammer and anvil effect of the vocal processes colliding against each other, leading to superficial mucosal ulceration (the contact ulcer) and focal granulation tissue response.[3]

Problem

A contact granuloma is a pale or sometimes red mass located on the medial aspect of the vocal process of the arytenoid cartilage. Histologically, contact granulomas resemble pyogenic granulomas, which consist of chronic inflammatory infiltration with neovascularization and fibrosis covered by squamous epithelium.

Classic contact ulcers are thought to be the result of vocal misuse and abuse. With this etiology, the lesion most commonly is identified in men. These lesions often are similar in appearance to those found in patients after intubation (intubation granulomas) and in patients with gastroesophageal reflux.

Occasionally, a vocal process granuloma is identified in a patient for whom none of these factors are apparent. de Lima Pontes et al label this group idiopathic. The literature contains much confusion about this entity; however, for practical purposes, these lesions may be conceptualized as a group.

Etiology

Primary causes of contact granulomas may coexist in the same patient and include the following:

  • Intubation (see video below)

    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.
  • Voice abuse

  • Laryngopharyngeal reflux disease

  • Idiopathic

Factors that contribute to the development of contact granulomas include smoking, allergy, infections, postnasal drip, and chronic throat clearing. Psychosocial traits associated with development of contact granulomas include aggressive personality, introversion, depression, emotional tension, and/or cancerophobia.

Certain dietary factors may affect the laryngeal milieu, leading to a detrimental mucosal environment. These factors include consumption of caffeine, chocolate, alcohol, peppermint, spicy foods, and tomato products; high-fat diet; poor water intake; and use of tobacco products. However, a direct causal relationship in the formation of contact ulcers has not been established.

Differential diagnoses include carcinoma, granular cell tumor of the larynx, and sarcoid.

Pathophysiology

Contact granulomas are usually pale, pedunculated masses found on the medial or superior edge of the vocal process of the arytenoid cartilage; however, they may also be deep red, lobulated, and sessile. These lesions may be 2-lipped structures that fit the vocal process of the opposite side.

Contact ulcers occur when the thin mucosa overlying the firm cartilage of the vocal process is crushed repetitively against the opposite side, causing a breakdown of the mucosa. An ulcer forms, accompanied by granulation tissue formation. An object such as an endotracheal tube may cause the injury leading to granulomas, or granulomas may result secondary to chronic irritation (eg, persistent gastroesophageal reflux injury).

A study by Li et al suggested that a finding of arytenoid cartilage sclerosis signals the presence of contact granuloma. High-resolution computed tomography (CT) scanning revealed that in patients with contact granuloma (41 with unilateral lesions and one with bilateral lesions), arytenoid cartilage sclerosis existed on 79.07% of the vocal folds with lesions, compared with 7.32% of those without lesions. The rate of arytenoid sclerosis associated with contact granuloma was also significantly greater than that for the lesion or nonlesion sides of vocal folds (13.11% or 2.56%, respectively) in patients with glottic laryngeal cancer or vocal cord leukoplakia without vocal process involvement.[4]

Presentation

Symptoms include the following:

  • Varying degrees of hoarseness and a low-pitched, pressed voice quality

  • Cough

  • Throat clearing

  • Pain, especially on pressed phonation or with cough or throat clearing

  • A rough foreign body sensation

The physician inquiry includes the following:

  • Intubation history, including nasogastric intubation

  • Reflux and associated high-risk habits (eg, dietary habits, caffeine intake)

  • Vocal use patterns (eg, glottal fry, hard glottal attack)

  • Pulmonary characteristics (eg, chronic cough, use of inhalers)

Indications

Even in relatively asymptomatic disease, treat the contact ulcer or vocal process granuloma to prevent growth and possible complications or sequelae of the inflammatory process, which include the following:

  • Airway obstruction

  • Bleeding (usually minor)

  • Vocal fold fixation

  • Posterior laryngeal stenosis

Surgical management of these lesions usually is frustrating because of a 37-50% recurrence rate. Surgical interventions are indicated for the following:

  • Fibroepithelial polyp

  • Airway compromise

  • Suspicion of carcinoma

Relevant Anatomy

Apices of the arytenoid cartilages are composed of elastic cartilage, and the rest of the arytenoid cartilage is hyaline cartilage. The arytenoid cartilages begin to ossify at approximately age 30 years. Ulcer or granuloma occurs on the vocal process of the arytenoid cartilage. The vocal process accounts for the posterior third of the vocal cord where the vocal ligament attaches.

The mucosa covering the vocal processes of the arytenoid cartilage is a thin layer of stratified squamous epithelium. This thin layer of mucosa is susceptible to being crushed between any unyielding object (eg, an endotracheal tube, the opposite arytenoid) and the firm cartilage beneath the mucosa.

Contraindications

Surgery is discouraged as the initial management for 2 reasons. Surgery is associated with a high recurrence rate of 37-50%, which often leads to multiple surgeries that may still be unsuccessful. Surgery may also cause the granuloma to migrate, following the wound edge.

 

Workup

Other Tests

See the list below:

  • 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)[5]

    • 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

See the list below:

  • 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.

 

Treatment

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[6]

    • 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 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.

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

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.

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.

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.

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

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[7] :

  • 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).[7]

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.[8]

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.