Subglottic Granuloma

Significance Statement

Subglottic granuloma presents with dysphonia and is associated with endotracheal intubation, laryngopharyngeal reflux, phonotrauma, and idiopathic causes. Early intervention helps prevent enlargement and potential airway obstruction. Physicians should suspect subglottic granuloma in patients who have undergone intubation or have laryngopharyngeal reflux and report hoarseness and throat discomfort. Anti-reflux medications and oral corticosteroids are recommended for subglottic granulomas. Surgical removal with steroid injection is effective for recurrent granulomas when medical management fails.

A 53 year-old electrician presented with a chief complaint of dysphonia. He was not a voice professional. Five years previously, the patient’s voice had become hoarse. He had been diagnosed with a vocal fold polyp and taken to the operating room (OR) at another institution for surgical excision. His voice remained hoarse and worsened progressively. He reported a history of smoking 1 pack per day for 25 years. The patient was advised to quit smoking, which he eventually accomplished. His past medical history was also significant for laryngopharyngeal reflux, for which he had not received treatment other than Tums before presenting to our office. Pantoprazole and ranitidine were prescribed, and he was instructed to drink alkaline water and begin voice therapy. Strobovideolaryngoscopy revealed a subglottic granuloma blocking part of the airway (Figure 1). The patient was taken to the OR for removal of the granuloma with bilateral vocal fold steroid injection. In the OR, the subglottic granuloma was resected with cold instruments, and dexamethasone was injected into the base. The procedure was performed under general anesthesia with jet ventilation. Photoangiolytic laser treatment of vocal fold varicosities was performed at the same time. Three months following surgery, he was doing well and there was no recurrence. His voice returned to baseline. He did not return for further follow-up.

Figure 1.

Strobovideolaryngoscopy demonstrates subglottic granuloma prior to excision.

Discussion

Subglottic granuloma is an inflammatory lesion in the subglottic region and usually presents with hoarseness, cough, throat pain, and occasionally dyspnea. ¹ The lesion begins as mucosal inflammation and causes epithelial tissue disorganization. It may then progress to ulceration, extend to the perichondrium and underlying cartilage, and be covered with inflamed granulation tissue. ² Histopathologically, it is not a granuloma as might be seen with tuberculosis or sarcoidosis. Subglottic granuloma typically arises as a complication of endotracheal intubation, acid laryngeal injury secondary to laryngopharyngeal reflux disease, phonotrauma, and idiopathic causes. ³ Poor nutritional status and dehydration also can compromise mucosal integrity and facilitate injury. ² The incidence of subglottic granuloma ranges from 0.01% to 3.5%. Females are particularly susceptible, potentially due to anatomical factors of the female larynx and short neck.^4,5 Conservative treatment options for subglottic granulomas include proton pump inhibitors, corticosteroids, antibiotics, voice therapy, smoking cessation, botulinum toxin, and anti-reflux diet. Microlaryngeal surgical excision of the granuloma with steroid injections is indicated after failure of pharmacological treatments and relapse.^2-6 Subglottic granuloma can develop 1 to 12 weeks after extubation and warrants careful attention due to its potential for acute airway obstruction.^2,7-9 Physicians should educate patients about the symptoms of subglottic granuloma, including progression and recurrence; and close follow-up is recommended.