Granulomas

Description

Contact ulcers and granulomas are non-cancerous growths that are found along the back part of the vocal folds.  Contact ulcers are raw sores on the top layer of the back part of the vocal fold and granulomas tend to grow over contact ulcers until cause of irritation is stopped or removed.  They can be found on one side or both sides of the vocal folds.

Cause

Contact ulcers and granulomas can result from Laryngopharyngeal Reflux (LPR) irritation where acid back-flows from the stomach into the esophagus and reaches the throat and upper airway.  The larynx has less protective mechanisms than the esophagus and it is more vulnerable to irritation and damage. 

Some factors contributing to acid reflux include:

  • Fatty foods
  • Chocolate
  • Caffeine
  • Alcohol
  • Cigarette smoking
  • Obesity
  • Pregnancy
  • Delayed stomach emptying

Contact ulcers and granulomas can also be caused from intubation trauma. They form because tissue becomes irritated by the intubation tube and as a reaction to the irritation, granulation tissue forms.  Often granulomas from intubation trauma can quickly resolve.

They have also been found to form due to vocal behaviors:

  • Talking loudly for extended periods of time
  • Shouting
  • Hard onset of sound
  • Excessive throat clearing
  • Excessive coughing

Symptoms

  • Globus sensation (feeling of a lump in the throat
  • Provoke chronic throat clearing
  • Coughing
  • Bitter taste in the mouth
  • Discomfort or pain
  • Hoarseness
  • Breathiness
  • Difficulty increasing vocal loudness
  • Reduced pitch range
  • Prolonged warm-up time

If one-sided, may have minimal to no change in voice quality.

Appearance

Commonly located on the back of the vocal folds

Larger granulomas can interfere with vocal fold closure

Smaller granulomas often result in normal vocal fold vibration and vocal fold closure.




Management

  • Intubation Granuloma
  1. Can resolve spontaneously
  2. Steroid injection
  3. Potassium titanyl phosphate laser ablation
        • Laryngopharyngeal Reflux Granulomas
            1. Diet and lifestyle modification
            2. Antacids
            3. H2-blockers
            4. Proton-pump inhibitor
            5. Promotility agents
            6. Surgery: Fundoplication
            • Granulomas associated with phonotrauma
              1. Voice therapy
              2. Patient education