Vocal Fold Granuloma Research Articles

Neuroendocrine tumor mimicking a recalcitrant vocal fold granuloma: Appearances can be deceiving.

Posterior glottic lesions resembling granulomas unresponsive to conservative treatment should raise suspicion of a neoplastic condition. Although surgery is rarely recommended for arytenoid granulomas due to their high recurrence rate, histological evaluation is mandatory in cases of uncertain diagnosis. Clinicians should be aware that, although very rare, a laryngeal neuroendocrine tumor occurring in the posterior glottis can mimic the appearance of an idiopathic granuloma, presenting a diagnostic challenge.

Benign Laryngeal Lesions

Benign laryngeal lesions represent a diverse set of pathologies whose clinical presentation may range from no symptoms to dyspnea and/or dysphonia. Flexible fiberoptic laryngoscopy and videolaryngostroboscopy are important in distinguishingdifferent types of lesions, and management and treatment are dependent on the identification of these lesions, as they have different etiologies. Some lesions such as vocal fold nodules and polyps are primarily phonotraumatic and may benefit fromspeech therapy and vocal hygiene as initial approaches. Vocal fold cysts and benign tumors may benefit from microlaryngeal approaches, while capillary ectasias, polypoid corditis, laryngoceles, saccular cysts, and papilloma may benefit from laser therapy. Vocal fold granulomas may arise from various etiologies such as intubation, traumatic behaviors, or reflux. Polypoid corditis arises from smoking. This review is intended to provide an overview of the variety of lesions that encompass non-malignant laryngeal lesions that is both suitable for junior and senior residents. This review contains 12 figures, 5 tables, and 64 references Keywords: Benign laryngeal lesions, Laryngocele, Polyp, Cyst, Polypoid Corditis, Papilloma

Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation.

Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT (P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (P = .042) in the multivariate analysis. Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.

Involvement of Laryngopharyngeal Reflux in Select Nonfunctional Laryngeal Diseases: A Systematic Review.

To investigate the existing published evidence supporting the role of laryngopharyngeal reflux (LPR) in the development of the select nonfunctional laryngeal diseases of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. PubMed, Cochrane Library, and Scopus. A systematic review was performed by 3 independent investigators for studies providing information about the prevalence and role of LPR in the development of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed with PRISMA criteria. Of the 64 relevant publications, 27 clinical and 4 basic science studies were included. Ten studies used objective reliable examinations for LPR diagnosis (eg, dual- or triple-probe or oropharyngeal pH monitoring, multichannel intraluminal impedance-pH monitoring, or pepsin detection). According to the bias analysis and the results of studies, the association between LPR and laryngotracheal stenosis, leukoplakia, laryngeal papillomatosis, or vocal fold granuloma remains poorly demonstrated. There is a notable heterogeneity among included studies regarding their inclusion criteria, diagnostic methods, and clinical outcome evaluation. Although some experimental findings support the involvement of bile salts and other gastroduodenal proteins active in alkaline pH, no included clinical studies assessed the role of nonacid and mixed reflux through multichannel intraluminal impedance-pH monitoring. The involvement of LPR in the development of leukoplakia, laryngotracheal stenosis, vocal fold granuloma, and laryngeal papillomatosis is currently not demonstrated. The potential relationship between LPR and these select nonfunctional laryngeal diseases must be confirmed through future clinical and experimental studies considering acid, nonacid, and mixed LPR.

The new in management of recurrent laryngeal granuloma: long term follow-up

Background/Aim: Vocal fold granuloma (VFG) is a nonspecific inflammatory process with no well-defined pathogenesis so its clinical and surgical treatment is not standardized. The aim of the study is to determine accurately the longest permissible period of conservative treatment of recurrent VFG, after which the decision of surgery must be made through long-term follow-up of cases with large recurrent posterior VFG, in addition to assessing the results of anew regimen in management of VFG. Material and Methods: this study conducted on 42patients with large recurrent posterior VFG that were on conservative management as long as the granulomas regress in size with follow-up intervals of 3 months through videolaryngoscope (VLS). Those with resistance VFG were subjected to surgical excision with intra-lesional steroid injection in the pedicle. Results: The most frequent related etiopathogenic factor was gastroesophageal reflux, followed by laryngeal intubation and idiopathic. Clinical management with proton pump inhibitor, systemic or local steroids and voice therapy in addition to behavior modification techniques were enough for remission on 80.95% of the patients. Surgical excision for granulomas was effective in 87.5% of the patients. Early recurrences were noticed in only one patient that proved to have a major gastroesophageal problem. Conclusion: VFG well responds to conservative treatment with complete recovery of maximum period 24months even if it is large and recurrent. Managing recurrent or large posterior VFG needs interdisciplinary team that involves an otolaryngologist, phoniatrician, gastroenterologist, and gastrointestinal surgeon. Voice abuse alone couldn't evoke the condition. Steroids are as important as anti-reflux medication in treatment of VFG.

Tracheal Stenosis After Endotracheal Intubation and Percutaneous Dilatational Tracheostomy

Introduction&#x0D; Tracheal stenosis is an abnormal narrowing of the tracheal lumen which affects adequate airflow and caused by an inflammatory complication such as endotracheal intubation and percutaneous dilatational tracheostomy (PDT). Incidence of tracheal stenosis following endotracheal intubation and PDT was 8-44%.&#x0D; Case Report&#x0D; A 24 year old female presented with dyspnea and hoarseness after traffic accident. She was intubated for 2 weeks then followed by PDT for 3 weeks. The laryngoscopy examination after PDT extubation showed tracheal stenosis at the second-third tracheal ring with left vocal fold granuloma. Cervical computed tomography demonstrated a mass at vocal cord and narrowing of tracheal caliber at the first thoracic vertebra disk, above the stoma of PDT.The granuloma was excised and tracheal stenosis was removed by tracheal resectionand end-to-end anastomosis. &#x0D; Discussion&#x0D; Tracheal stenosis is one of important sequelae after endotracheal intubationand PDT. Tracheal resection and primary anastomosis may be considered as an option for surgical management of tracheal stenosis.

Ideal Particle Sizes for Inhaled Steroids Targeting Vocal Granulomas: Preliminary Study Using Computational Fluid Dynamics.

Objectives Vocal fold granulomas are benign lesions of the larynx commonly caused by gastroesophageal reflux, intubation, and phonotrauma. Current medical therapy includes inhaled corticosteroids to target inflammation that leads to granuloma formation. Particle sizes of commonly prescribed inhalers range over 1 to 4 µm. The study objective was to use computational fluid dynamics to investigate deposition patterns over a range of particle sizes of inhaled corticosteroids targeting the larynx and vocal fold granulomas. Study Design Retrospective, case-specific computational study. Setting Tertiary academic center. Subjects/Methods A 3-dimensional anatomically realistic computational model of a normal adult airway from mouth to trachea was constructed from 3 computed tomography scans. Virtual granulomas of varying sizes and positions along the vocal fold were incorporated into the base model. Assuming steady-state, inspiratory, turbulent airflow at 30 L/min, computational fluid dynamics was used to simulate respiratory transport and deposition of inhaled corticosteroid particles ranging over 1 to 20 µm. Results Laryngeal deposition in the base model peaked for particle sizes 8 to 10 µm (2.8%-3.5%). Ideal sizes ranged over 6 to 10, 7 to 13, and 7 to 14 µm for small, medium, and large granuloma sizes, respectively. Glottic deposition was maximal at 10.8% for 9-µm-sized particles for the large posterior granuloma, 3 times the normal model (3.5%). Conclusion As the virtual granuloma size increased and the location became more posterior, glottic deposition and ideal particle size generally increased. This preliminary study suggests that inhalers with larger particle sizes, such as fluticasone propionate dry-powder inhaler, may improve laryngeal drug deposition. Most commercially available inhalers have smaller particles than suggested here.

Treatment Outcomes of In-Office KTP Ablation of Vocal Fold Granulomas.

To determine the effectiveness of in-office potassium-titanyl-phosphate (KTP) treatment of vocal fold granulomas and identify any predictors of complete lesion resolution. A retrospective review of patients who underwent in-office KTP ablation of vocal fold granulomas between 2007 and 2016 was performed. Medical records were reviewed for use of acid suppression medication, prior surgical treatment, voice therapy, laser settings, number of treatments, follow-up time, and Voice Handicap Index-10 (VHI-10) scores. Twenty-six patients underwent a total of 43 laser treatments. Eighty percent of patients were previously on acid suppression medication, and 42.3% had failed previous endoscopic treatments. Patients underwent a mean number of 1.65 ± 1.16 in-office treatments with decrease in size in 96.2% of cases. The VHI-10 was not significantly affected. Complete resolution occurred in 73.1% of cases with follow-up time ranging from 1 to 86 months (median = 9.5 months). No recurrences occurred in patients with complete resolution. Other than undergoing a single KTP treatment, no variable was found to be predictive of complete lesion resolution. Granuloma etiology was not predictive of lesion resolution but did correlate with symptom improvement. In-office pulsed KTP laser is an effective treatment option for vocal fold granulomas as the lesion resolves in the majority of cases.

Bilateral vocal fold granulomas following double-lumen endotracheal tube placement.

Bilateral vocal fold granulomas following double-lumen endotracheal tube placement.

Persistent Vocal Fold Granuloma Following Superficial PAAG Injection Laryngoplasty: A Case Report

The injection material polyacrylamide hydrogel (PAAG; Ferrosan, Søborg, Denmark) is often used as space filler for soft-tissue defects. PAAG is a suitable alternative to the materials used for injection laryngoplasty. Over the past decade, 427 patients have undergone injection laryngoplasty in our clinic using PAAG, and no major complications, such as material migration or foreign body granuloma, were identified. Here, we report the case of the first woman to undergo laryngomicrosurgery to remove a vocal fold granuloma that developed after a superficial injection laryngoplasty performed 4 years previously.

A Simple Voice Training Method for Inflammatory Laryngeal Diseases by Relying on Abdominal Respiration

Background: It has been suggested that doctors should perform voice therapy in cooperation with speech therapists, but there are few speech therapists in Japan. Therefore, at our hospital otorhinolaryngology out-patient clinic, voice therapy is performed by a single doctor (first author) using a simple method of voice training that relies on the abdominal type of respiration. Voice therapy is considered the first choice for vocal fold nodules. We tried this voice training method for vocal fold polyps and laryngeal granulomas with resistance to proton pump inhibitor (PPI) as well as vocal fold nodules. Methods: At our hospital otorhinolaryngology out-patient clinic, voice therapy was performed using a simple method of voice training that relies on abdominal respiration for inflammatory laryngeal diseases. Results: All 16 cases with vocal fold nodules showed disappearance of symptoms by our method of voice training. Nine of 12 cases with vocal fold polyps and 12 of 15 cases with laryngeal granulomas showed disappearance or reduction of symptoms. Conclusions: These results suggested that our method of voice training could be useful for some cases of both vocal fold polyps and laryngeal granulomas in the same way as vocal fold nodules.

Successful management of a patient with massive vocal fold granuloma with transglottal jet ventilation.

A 50-year-old man weighing 48 kg was admitted to the hospital after suffering breathing difficulty and hoarseness for two weeks. During endoscopic examination, a squishy mass that occupied 80-90% of the glottic opening was observed (Fig. 1). The stalk was located on the left side just above the vocal cords and it moved slightly in and out of the glottis when the patient breathed. The patient entered the operating room in a sitting position and was given 100% oxygen with a nasal prong. Once on the operating table, the patient was placed in the semi-Fowler's position. It was anticipated that when he lost consciousness from anesthesia induction, mask ventilation would no longer work due to his totally obstructed airway. We therefore decided to perform transtracheal jet ventilation (TTJV) using a percutaneous transtracheal catheter.

Multilevel Airway Involvement in Children With Wegener's Granulomatosis

To examine the prevalence of airway involvement in children with Wegener's granulomatosis (WG) at our institution and to evaluate the utility of a treatment paradigm involving a multidisciplinary team. Retrospective medical chart review. Tertiary children's hospital. Pediatric subjects with WG treated at a tertiary children's hospital over the past 15 years. The medical records of all subjects with airway lesions were reviewed for clinical characteristics of airway involvement and for the medical and surgical treatment regimens. Seven of 28 pediatric patients with WG were identified to have airway lesions (25%), including vocal fold granuloma, subglottic stenosis, and multilevel stenoses. Three of these patients had isolated and limited lesions. The 4 remaining patients are the focus of this study. One patient underwent a cricotracheal resection. All patients underwent repeated surgical treatment from combined services (otolaryngology and pulmonology) with flexible and rigid endoscopy, dilatation, and corticosteroid injection to manage subglottic, tracheal, and bronchial stenoses. Operative findings were communicated to the rheumatology service for manipulation of medical therapy. The 3 most recent patients received the anti-CD20 chemotherapeutic agent rituximab. This treatment approach led to temporary remission in some of the patients. Airway involvement in pediatric patients with WG is known to occur, but multilevel airway involvement is rare and clinically challenging. We advocate a combined surgical approach involving otolaryngology, pulmonology, and rheumatology in managing aggressive cases of multilevel airway involvement in WG.

Coblation removal of laryngeal Teflon granulomas

AbstractLaryngoscope, 2010

The Role of Proton Pump Inhibitors in Reducing Laryngeal Injury During Prolonged Intubation

Methods: Adult subjects were prospectively enrolled and underwent video-recorded transnasal fiberoptic laryngoscopy following extubation in the medical intensive care unit. Variables recorded include: duration of intubation, size of endotracheal tube, and administration of proton pump inhibitor versus H-2 blocker during intubation. The laryngoscopy examinations were blindly reviewed and laryngeal injuries that were documented include: presence of vocal fold immobility, vocal fold granuloma, and laryngeal erythema or ulceration.

Clinical, histological and electron microscopic aspects of vocal fold granulomas

SummaryGranulomas are bilateral and pediculated lesions of the vocal apophysis. Etiologies: intubation, reflux, trauma, vocal abuse, idiopathic origin. Aim: To analyze the clinical and morphological aspects of post intubation granulomas. Methods: retrospective study of patients submitted to microsurgery for post intubation laryngeal granulomas seen at our Medical School starting in 2002. We analyzed: age, gender, indication and time of intubation, symptoms, videolaryngoscopic diagnosis and biopsy findings. Light microscopy was performed on all specimens, and electron microscopy on three of them. Results: ten patients (7 females and 3 males), between the ages of 2 and 72 years, intubation time between 4h and 21 days. Hoarseness was a frequent symptom, starting in the first week following extubation. Histology shows mild epithelial hyperplasia, severe inflammation and vessel proliferation in the corion. Under SEM, the epithelium presented mild superficial desquamation. Under TEM, intracellular junctions showed widening with structural changes in the desmosomes. In the corion there were vessel proliferations, inflammation and fibroblasts with structural alterations. Conclusions: post intubation granulomas appear in any age and hoarseness is a frequent symptom. Morphological alterations occur in the corion as vessel proliferations, inflammation, and intracytoplasmatic alterations in fibroblasts suggesting cellular dysfunction and damage.

Granuloma of the Membranous Vocal Fold: An Unusual Complication of Microlaryngoscopic Surgery

We describe the clinical features of granuloma of the membranous vocal fold (as opposed to granuloma of the vocal process, or "contact granuloma"), a poorly recognized sequela of microlaryngoscopic surgery. Membranous vocal fold granuloma may mimic the initial lesion in appearance, and thus be mistaken for recurrence. We performed a retrospective review of cases from 2 institutions. Fifteen cases of membranous vocal fold granuloma from 2 institutions were identified. In all but 1 case, granuloma developed in the early postoperative period, within 8 weeks. Of the 15 cases, 10 followed laser resection of carcinoma. Five were noted following cold steel resection of benign lesions (2 papillomas, 2 cysts, 1 Reinke's edema). Technical aspects of these cases suggest that membranous vocal fold granulomas result from surgical violation of deep tissue planes and/or epithelial defects. All patients were treated with proton pump inhibitors. In 12 cases, the granulomas proved self-limited, resolving over weeks to months following surgery. Three patients underwent surgical removal of the lesion, which confirmed the diagnosis. One of these cases recurred and was treated nonsurgically. Granuloma should be suspected when a mass lesion appears at the surgical site early in the postoperative course. Surgical excision is generally not necessary and may provoke further growth of granulation tissue.

Conservative Treatment of an Obstructing Vocal Fold Granuloma

Conservative Treatment of an Obstructing Vocal Fold Granuloma

DNA microarray gene expression analysis of a vocal fold polyp and granuloma.

Genome-wide transcriptional profiling has important applications in advancing knowledge of vocal fold biology. With the use of DNA microarray technology, analysis of global patterns of gene expression can reveal unexpected networks of coordinated regulation in the extracellular matrix of the lamina propria. Transcriptional gene expression patterns for 2 vocal fold pathologies--vocal fold polyp (VP; N = 1) and vocal fold granuloma (VG; N = 1) were analyzed by means of DNA microarray analysis for 4,632 human genes using another patient's true vocal fold (TVF; N = 1) as a control. Twenty-four and 29 genes for VG and VP, respectively, were established to be either over- or underexpressed compared to that of TVF. Five-way cluster analysis revealed broad patterns that suggest a potential degree of organization underlying gene expression in these tissues. For the 1 VG, genes involved represent inflammation and wound healing; for the 1 VP, involved genes demonstrate a tempered wound repair response and increased epithelial manifestations. These results successfully demonstrate the use of DNA microarray technology as a new approach for further investigations dissecting vocal fold disease. Further investigation is needed on larger sample sizes to establish transcriptional gene expression patterns for VP and VG.

Vocal fold granuloma: Successful treatment with botulinum toxin

Vocal fold granulomas are benign but frequently recurrent lesions that can cause frustration for both the patient and the treating physician. Etiologic factors include endotracheal intubation, vocal abuse, and gastroesophageal reflux. Conventional treatment for granulomas has included medical, voice, and surgical therapy, none with uniform success. In this study 8 patients with vocal fold granulomas were treated with intralaryngeal injection of botulinum toxin. The resultant temporary paresis of the vocal folds allowed for a window of time during which the vocal process could heal and the granulomas could resolve without being exposed to ongoing intermittent contact and friction with the opposing arytenoid. Although the underlying cause of a granuloma must also be addressed, we have found that botulinum toxin can be a useful adjunct to traditional therapy and can lead to avoidance of repetitive surgical procedures. (Otolaryngol Head Neck Surg 1999;121:410-3.)