Vocal Cord Granuloma
Such are the symptoms commonly associated with a benign growth of the voicebox called a granuloma. Though patients (and even physicians) may refer to such growths as a vocal cord granuloma, in reality, such growths almost always occur in structures near the vocal cord, but not on it. The most common location for granulomas of the voicebox is on the vocal process which is the "hinge" that allows the vocal cords to move.
In the diagram below, one can see what a normal voicebox looks like:
In the picture, the thin white blades are the true vocal cords. When they move apart, air can move in between the vocal cords into the lungs allowing a person to breathe. When they come together with talking or singing, they vibrate creating the voice. Watch a video to see how a normal voicebox works.
The take-home point here is that the vocal cords come together to create a voice. As such, for unclear reasons, when the voice is abused (screaming, yelling, or just plain talking too much), the end of the vocal cords aggressively hinge open and closed resulting in irritation triggering an exuberant reaction leading to the development of a granuloma as shown to the right (needle pointing to the granuloma). It is also suspected that acid reflux predisposes to granuloma formation as well. When repeated injury occurs whether due to talking and/or acid reflux, the granuloma gets further irritated driving its growth.
Treatment is by addressing the underlying triggers that caused the granuloma to occur in the first place. As such, restricted voice use (no "social" talking, absolutely no vocal abuse like yelling/screaming, etc) as well as taking a proton pump inhibitor reflux medication to prevent any possibility of acid exposure to the area is mandatory. Ideally, voice therapy should also be pursued to ensure proper voice patterns to prevent further (re)-injury. In the vast majority of cases, with such conservative management, the vocal process granuloma resolves over several months. Take a look at the pictures below that show a large vocal process granuloma that resolved over several months with voice rest and reflux medications alone.
Each image was obtained from the same patient spaced about 1.5 months from each other. So the timing between the first and last image was a total of 3 months. To reiterate, this improvement occurred with strict voice rest and proton pump inhibitor taken twice a day.
If there is no improvement after a period of time, surgical excision is recommended to make sure that the mass is truly a granuloma and not due to some other pathology like cancer.
Once pathology confirms granuloma, steroid injections to the mass can be pursued to try and prevent the underlying inflammation that drives granuloma formation. Such steroid injections can be done without the need for sedation and can be accomplished endoscopically while awake minimizing post-operative recovery (patients often go back to work right after the procedure). Repeated injections are typically required before the granuloma fully resolves. Of course, thoughout this treatment, the patient is still required to be on restricted voice use as well as taking reflux medications. Watch the video below on a steroid injection being performed to a vocal cord granuloma. There has also been some suggestion that pulmicort inhaler use may be helpful in granuloma resolution.
Another good option to try is botox injection which can be administered into the vocal cord muscle to prevent the vocal cords from coming together thereby preventing the granuloma site from being "hit" from the other side when talking. The video shown here describes this procedure, though the condition being treated is for a different reason (spasmodic dysphonia).
If re-excision of the granuloma is required, mitomycin C can be applied as well as post-procedure laser treatment using PDL or KTP can be performed to try and suppress recurrence.
If you are suffering from a voicebox granuloma, please contact our office for an appointment.
Comparison of treatment modalities for contact granuloma: A nation-wide multicenter study. Laryngoscope. 2013 Oct 15. doi: 10.1002/lary.24470. [Epub ahead of print]
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