Contact granuloma

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Contact granuloma
Other namesContact ulcer, Vocal fold contact ulcer or Vocal process granuloma
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Healthy vocal folds. Contact granulomas may form in the posterior part of the larynx.
Specialty Otolaryngologist

Contact granuloma is a condition that develops due to persistent tissue irritation in the posterior larynx. [1] [2] Benign granulomas, not to be confused with other types of granulomas, occur on the vocal process of the vocal folds, where the vocal ligament attaches. Signs and symptoms may include hoarseness of the voice, or a sensation of having a lump in the throat, but contact granulomas may also be without symptoms. [3] There are two common causes associated with contact granulomas; the first common cause is sustained periods of increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively, such as singers (John Mayer, for example). [4] Treatment typically includes voice therapy and changes to lifestyle factors. The second common cause of granulomas is gastroesophageal reflux and is controlled primarily through the use of anti-reflux medication. [5] Other associated causes are discussed below.

Contents

Signs and symptoms

The primary symptoms of contact granuloma include chronic or acute hoarseness of the voice and vocal fatigue. [6] [7] More severe granulomas may result in throat ache or soreness, as well as pain that spreads to one or both ears. [1] [7] Smaller granulomas may result in a tickling sensation or slight discomfort.

Signs of contact granulomas are frequent coughing and throat-clearing. [7] [5] Some people may also notice that their pitch range is restricted due to granuloma. [1]

Causes

The major etiologic factors of contact granulomas have been organized into the following categories:

Mechanical issues

Mechanical issues resulting in contact granulomas are related to physical trauma at the level of the vocal folds. [1] [8] Trauma occurs when adductive forces are excessive, meaning that a person's vocal folds are closing abruptly and forcefully while speaking or engaging in other non-vocal behaviors (such as throat-clearing and coughing). [1] [5] [8] In addition, the presence of the contact granuloma makes it impossible for the vocal folds to come to a complete closure in adduction. This causes the person to use more force when speaking in an attempt to close the vocal folds completely, which in turn creates more trauma to the vocal folds. [9]

Glottal insufficiency (when the vocal folds cannot close completely, often due to vocal fold paralysis) can also be an underlying cause of contact granulomas. [5]

Contact trauma can occur when a person frequently speaks at a pitch that is lower than their modal voice, especially in vocally-demanding professions like acting, teaching and singing. [1] Research suggests that men are more commonly affected than women. [5] [8]

Inflammatory issues

Inflammatory issues associated with contact granuloma include gastroesophageal reflux, allergy or infection. [1] [5] [10] There is some disagreement among researchers as to whether inflammatory issues are a direct cause. [8] Some researchers identify reflux and infection as indirect causes due to aggressive coughing that usually occurs as a result.[ citation needed ]

Intubation

For patients in need of tracheal intubation to receive oral drugs, an oversized tube, excessive movement of the tube, or infection can lead to contact granulomas, but this is rare. [1] [5] [8]

Psychosocial factors

People with certain personality traits and vocal patterns may be more susceptible to the development of contact granulomas. [8] [10] [11] Tenseness, high-stress, aggressiveness and impulsiveness are personality traits associated with contact granuloma. [5] [8]

Diagnosis

Diagnosis of contact ulcers normally involves an endoscopy examination, and a biopsy sample is taken so that the ulcer can be examined for cancerous cells.

Physical characteristics

Contact granulomas can be physically identified and diagnosed by observing the presence of proliferative tissue originating from the vocal process of the arytenoid cartilage. [5] Identification is carried out by laryngoscopy, which produces an image of the lesion in the form of an abnormal growth (nodule or polyp) or ulceration. [8] [5] The vocal process is overwhelmingly the most common laryngeal site for these lesions, although they have also been observed on the medial and anterior portions of the vocal folds. [8] In nodule or polyp form, contact granulomas generally have a grey or dark red colouring [8] [5] and measure 2 to 15 mm in size. [5] Contact granulomas can occur unilaterally or bilaterally, affecting one or both vocal folds. [8] [5]

Differential diagnosis

Various methods are used to diagnose contact granuloma which aid in differentiating it from other vocal fold pathology. [12] [13] [3] [8] Laryngoscopy can allow visualization of the suspected granuloma while also checking for signs of vocal abuse. [12] [8] Laryngoscopy, as well as an acoustic analysis of the voice, can help rule out vocal fold paresis as an underlying cause. [12] [8] Microscopic examination of the tissue can help determine that the lesion is benign rather than cancerous, as would be the case in contact granuloma. [8] Other methods such as laryngeal electromyography and reflux testing can also be used to evaluate the function of the vocal folds and determine if laryngopharyngeal reflux is contributing to the pathology. [12]

Screening

Screening tools for contact granulomas are not currently available. Diagnosis of contact granulomas require visualization using laryngoscopy, and may require further biopsy for differential diagnosis. [8] A combination of symptoms and lifestyle factors may be linked with the development of a contact granuloma, however symptoms vary greatly by individual. Some lifestyle factors that have been linked with elevated risk of development of contact granulomas include frequent use of the voice, especially when in loud environments, and concurrent use of the voice with alcohol consumption (increasing risk of gastroesophageal reflux symptoms). Contact granuloma may also arise after intubation, and so following intubation, patients should be monitored if voice symptoms arise. Symptoms may or may not include hoarse voice, described as "huskiness" by some patients, [5] "aching" in the throat related to increased effort to produce voice, [5] and the feeling of having a lump in one's throat when swallowing. [5] It is also possible to have no such symptoms, especially if the granuloma is small. [5] A patient presenting with such symptoms or risk factors should therefore be referred for further visualization. It is therefore recommended to obtain a diagnosis from a doctor.[ citation needed ]

Prevention

The causes of vocal process granulomas are quite varied, and as such prevention must target the individual causes. [8] Education on lifestyle factors such as habitual vocal abuse and habits that may aggravate gastro-esophageal reflux should be implemented to lower risk, and those who use their voice professionally should use vocal hygiene techniques to ensure safe voice use. [8] Vocal hygiene may include increasing water intake, eliminating external irritants such as smoking or airborne chemicals, controlling loudness, and balancing periods of increased vocal use with periods of rest. [14] Since intubation can also cause vocal process granulomas, proper muscle relaxing medications should be used before insertion and removal of tubes, that smaller tubes are used and with proper lubrication, and that patient movement is controlled during intubation. [8]

Treatment

Specific treatment for contact granuloma depends on the underlying cause of the condition, but often initially includes a combination of speech therapy, [8] [12] [13] [3] vocal rest, [8] [12] [13] and antireflux medication. [13] [3] A more aggressive treatment approach could include steroids (inhalant or injection), [13] [3] injections of botulinum toxin, [8] [12] [13] [3] low dose radiotherapy, vocal fold augmentation, [8] or microlaryngeal surgery). [12] [13] [3] Microlaryngeal surgery can be performed either via cold steel excision or various types of laser. [3] The laser is more accurate and typically results in less damage to the surrounding tissue. These more aggressive approaches might be used in the case of the refractory (i.e. resistant to treatment) contact granuloma where previous interventions have not succeeded or recurrence rates are high. [8] The best outcomes appear to occur when a combination of treatments is used. [3]

Steroids

The application of corticosteroids to treat contact granulomas is considered a more extreme approach [8] and its utility remains in contention. [8] [5] When employed, it is usually used in conjunction with antibiotics for the reduction of pain and inflammation related to the granuloma. [5] This treatment can be administered orally, through inhalation, or through intralesion injection. [5]

Botox injection

The injection of botulinum neurotoxin A, or Botox, to treat contact granulomas is considered a more extreme approach, [8] and is generally only pursued when the case has been resistant to other treatments. [5] [3] In this approach, Botox is injected into the thyroarytenoid muscle (unilaterally or bilaterally), targeting a reduction in the contact forces of the arytenoids. [5]

Surgery

When all other medical and behavioural treatments have been attempted, surgical removal of the contact granuloma is possible as a last resort option. However, caution needs to be exercised, especially in the cases of contact granuloma resulting from external factors (i.e., when factors are eliminated, the contact granuloma resolves independently), because any irritation can cause the contact granulomas to reappear. [2]

Prognosis

As the masses of granular tissue are most often benign, prognosis is generally positive. [5] However, due to the variety of treatment options and lifestyle factors, outcomes of individual treatments and form of management vary. A high proportion of contact granulomas are present in patients with concurrent gastroesophageal reflux, and so treatment of the reflux is imperative. [3] Those caused by intubation trauma are less likely to recur. [8] The most common treatment is voice therapy by a speech-language pathologist, and this therapy is enough for many patients. [3] Surgical solutions are sometimes used, however rates of recurrence are higher. [3] Most recent research suggests that surgical options should only be explored once treatment of reflux with or without voice therapy has been introduced. [3]

Epidemiology

Across all posited etiologies, contact granulomas are more commonly observed in male patients than in female patients, and more commonly in adult patients than in pediatric patients. [8] In cases where gastroesophageal reflux disease is identified as the most likely cause of the granuloma, the patient is most commonly an adult man in his 30s or 40s. [8] When contact granulomas do occur in female and pediatric patients, they usually occur post-intubation. [8] There are no observable age or gender trends within the category of post-intubation patients with contact granulomas, nor within the causation category of vocal abuse history. [8]

Terminology

Several different terms are used to refer to contact granulomas (contact ulcer, vocal fold granuloma, vocal process granuloma, etc.). The term contact ulcer was first used in the early 20th century at which time the single cause of this condition was believed to be excessive force when the vocal folds make contact during phonation or non-phonatory behaviors (i.e. coughing). [5] Later, the same condition was observed in patients recovering from recent intubation [5] and, more recently, came to be associated with inflammation and irritation resulting from gastro-esophageal reflux. [5]

Likewise, use of both ulcer and granuloma reflect the fact that this condition can present as an ulcerated lesion or as granulated tissue. [1]

In medical literature today, the term vocal process granuloma is preferred over the term contact ulcer or contact granuloma; this reflects the fact that this condition can result from a variety of different causes and not just excessively forceful contact of the vocal folds as was originally believed. [15] [5] Nevertheless, the term contact granuloma remains widely used.

Sources

Related Research Articles

Vocal cord nodules are bilaterally symmetrical benign white masses that form at the midpoint of the vocal folds. Although diagnosis involves a physical examination of the head and neck, as well as perceptual voice measures, visualization of the vocal nodules via laryngeal endoscopy remains the primary diagnostic method. Vocal fold nodules interfere with the vibratory characteristics of the vocal folds by increasing the mass of the vocal folds and changing the configuration of the vocal fold closure pattern. Due to these changes, the quality of the voice may be affected. As such, the major perceptual signs of vocal fold nodules include vocal hoarseness and breathiness. Other common symptoms include vocal fatigue, soreness or pain lateral to the larynx, and reduced frequency and intensity range. Airflow levels during speech may also be increased. Vocal fold nodules are thought to be the result of vocal fold tissue trauma caused by excessive mechanical stress, including repeated or chronic vocal overuse, abuse, or misuse. Predisposing factors include profession, gender, dehydration, respiratory infection, and other inflammatory factors.

Vocal fold cysts are benign masses of the membranous vocal folds. These cysts are enclosed, sac-like structures that are typically of a yellow or white colour. They occur unilaterally on the midpoint of the medial edge of the vocal folds. They can also form on the upper/superior, surface of the vocal folds. There are two types of vocal fold cysts:

  1. Sub-epithelial vocal fold cysts- located in the superficial lamina propria of the vocal folds.
  2. Ligament vocal fold cysts- located within the deeper layers of the lamina propria or on the vocal ligament.
Reinkes edema Medical condition

Reinke's edema is the swelling of the vocal cords due to fluid (edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.

Gastroesophageal reflux disease Medical condition

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic condition in which stomach contents and acid rise up into the esophagus, resulting in symptoms and/or complications. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, regurgitation, breathing problems, and wearing away of the teeth. Complications include esophagitis, esophageal stricture, and Barrett's esophagus.

Laryngitis Medical condition

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.

Post-nasal drip Medical condition

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

Laryngeal papillomatosis Medical condition

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.

Bogart–Bacall syndrome

Bogart–Bacall syndrome (BBS) is a voice disorder that is caused by abuse or overuse of the vocal cords.

Hoarse voice Voice disorder

A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice, can be associated with a feeling of unease or scratchiness in the throat. Hoarseness is often a symptom of problems in the vocal folds of the larynx. It may be caused by laryngitis, which in turn may be caused by an upper respiratory infection, a cold, or allergies. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting one's voice, singing loudly, or speaking with a voice that's too high or too low can also cause temporary hoarseness. A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems.

Globus pharyngis Medical condition

Globus pharyngis or globus sensation is the persistent but painless sensation of having a pill, food bolus, or some other sort of obstruction in the throat when there is none. Swallowing is typically performed normally, so it is not a true case of dysphagia, but it can become quite irritating. It is common, with 22–45% of people experiencing it at least once in their lifetime.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Spasmodic dysphonia, also known as laryngeal dystonia, is a disorder in which the muscles that generate a person's voice go into periods of spasm. This results in breaks or interruptions in the voice, often every few sentences, which can make a person difficult to understand. The person's voice may also sound strained or they may be nearly unable to speak. Onset is often gradual and the condition is lifelong.

Puberphonia is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a ‘falsetto’ voice. The voice may also be heard as breathy, rough, and lacking in power. The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. This disorder usually occurs in the absence of other communication disorders.

Laryngopharyngeal reflux Medical condition

Laryngopharyngeal reflux (LPR) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.

Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation.

Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), or laryngopharyngeal sensory testing, is a technique used to directly examine motor and sensory functions of swallowing so that proper treatment can be given to patients with swallowing difficulties to decrease their risk of aspiration and choking. FEESST was invented by Dr. Jonathan E. Aviv MD, FACS in 1993, and has been used by otolaryngologists, pulmonologists, gastroenterologists, intensivists and speech-language pathologists for the past 20 years.

Endoscopic laser cordectomy, also known as Kashima operation, is an endoscopic laser surgical procedure performed for treating the respiratory difficulty caused as a result of bilateral abductor vocal fold paralysis. Bilateral vocal fold paralysis is basically a result of abnormal nerve input to the laryngeal muscles, resulting in weak or total loss of movement of the laryngeal muscles. Most commonly associated nerve is the vagus nerve or in some cases its distal branch, the recurrent laryngeal nerve. Paralysis of the vocal fold may also result from mechanical breakdown of the cricoarytenoid joint. It was first described in by Kashima in 1989.

Oral manifestations of systematic disease are signs and symptoms of disease occurring elsewhere in the body detected in the oral cavity and oral secretions. High blood sugar can be detected by sampling saliva. Saliva sampling may be a non-invasive way to detect changes in the gut microbiome and changes in systemic disease. Another example is tertiary syphilis, where changes to teeth can occur. Syphilis infection can be associated with longitudinal furrows of the tongue.

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion.

Intubation granuloma Medical condition

Intubation granuloma is a benign growth of granulation tissue in the larynx or trachea, which arises from tissue trauma due to endotracheal intubation. This medical condition is described as a common late complication of tracheal intubation, specifically caused by irritation to the mucosal tissue of the airway during insertion or removal of the patient’s intubation tube.

References

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  4. ↑ McKINLEY Jr., JAMES (2011-11-18). "Advances in Medicine Lead Stars to Surgery". The New York Times. Retrieved 6 April 2013.
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  11. ↑ Kleinsasser, O. (1986). Microlaryngoscopic and histologic appearances of polyps, nodules, cysts, Reinke's edema, and granulomas of the vocal cords. San Diego, CA: College-Hill Press. pp. 51–55.
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