Abstract
Stroboscopic examination of a 14-year-old boy with a 10-month history of dysphonia detected a sessile vocal fold mass that originated near the left vocal process and extended along the proximal one-third of the superior surface of the musculomembranous vocal fold. Examination also revealed the presence of reflux laryngitis.
The patient was treated with a twice-daily protonpump inhibitor, a nightly H2 blocker, lifestyle moditions, and voice therapy. However, his compliance poor, and he subsequently underwent microdirect laryngoscopy with excisional biopsy of the left vocal i mass. Pathology identified the lesion as a pyogenranuloma. Additional voice therapy and antireflux therapy were prescribed.
Over the next 9 months, the patient's compliance with his prescribed treatment regimen was poor, and the mass recurred. By then, he was experiencing hoarsenes, breathiness, and voice fatigue. He was re-educated about lifestyle modifications, reflux control, and the importance of voice therapy, yet despite these efforts, the granuloma persisted and enlarged.
A 24-hour pH impedance study confirmed multiple episodes of laryngeal acid exposure, and the dose of the proton-pump inhibitor was increased. Microdirect laryngoscopy with excision of the mass and bilateral injections of botulinum toxin into the lateral cricoarytenoid muscles were performed. Compliance with the subsequent treatment recommendations was better, and the patient's voice improved markedly. Stroboscopic examination detected a small area of granuloma Persistence/recurrence.
After 3 months of treatment without a complete resolution of the granuloma, intracranial corticosteroid injections were administered in either the operating room or the office on a dozen occasions over about 8 months. During the next year, reflux control, lifestyle modifications, and voice therapy were stressed. However, compliance again became poor, and the granuloma recurred, extending beyond its original borders to involve the deeper layers of the vocal fold (figure). The patient subsequently underwent another surgical resection of the granuloma and bilateral botulinum toxin injections to the lateral cricoarytenoid muscles. At 6 months of follow-up, he remained asymptomatic and free of granuloma.
Rigid videostroboscopy shows the mature sessile recurrent granuloma on the left vocal process. This new lesion extends beyond the borders of the original lesion and involves the deeper layers of the vocal fold
Pyogenic granulomas of the larynx are usually solitary lesions that may ulcerate and hemorrhage, interfering with the vibration of the vocal folds. Large granulomas may prolapse into and obstruct the airway. 1
Granulomas usually occur as the result of irritative or traumatic injury to the affected surface, 2 the most common etiology being uncontrolled laryngeal reflux. Although the term granuloma is accepted universally, these laryngeal lesions are actually not granulomas histopathologically, but rather chronic inflammatory lesions. 3 Granulomas of the larynx can cause dysphonia by direct mechanical disruption of the mucosal wave, either by acting as a spacer between the vocal folds and preventing contact or by partially disrupting air flow through the glottis.
The multiple recurrences in our patient illustrate the importance of compliance with prescribed treatment recommendations. Pharmacologic treatment consists of a proton-pump inhibitor at least twice daily and a nightly H2 blocker. The efficacy of treatment can be assessed with a 24-hour pH impedance study; higher doses of medication may be appropriate if objective testing confirms persistent, significant acid production. Lesions refractory to medical therapy may require surgical excision. 4
For granulomas that are refractory to medical and/or surgical therapy and for recurrent lesions, it is reasonable to consider botulinum toxin injections into the lateral cricoarytenoid muscles along with local and/or systemic steroid therapy. 3 Patients occasionally develop multiple recurrent granulomas even after excellent reflux control (including fundoplication), voice therapy, surgical removal (including steroid injection into the base of the granuloma), angiolytic laser therapy, and other treatments. It is important to rule out medical causes other than reflux and muscular tension dysphonia, particularly granulomatous diseases (e.g., sarcoidosis and tuberculosis) and neoplasms (e.g., granular cell tumors). 3