Pathology of the Head and Neck

210 N. Gale · A. Cardesa · N. Zidar7Fig. 7.7. Intubation granuloma. a Exophytic intubation granulomalocated on the posterior third of the right vocal cord. b Polabypoid granulation tissue is ulcerated with re-epithelialisation atthe edgeRarely, scattered atypical stromal cells, not associatedwith increased mitotic activity, may be found within thecore of the VCP. This finding must not incorrectly leadto a diagnosis of malignancy [383].In the initial stage, VCNs show diffusely oedematoustissue with distended capillaries and venules and tinyperivascular haemorrhages surrounded by a minimal ormoderate inflammatory reaction. In time, the loose connectivestroma is replaced by a mild to moderate cellularfibrous tissue changing in varying stages of evolution.As previously mentioned, the covering squamous epitheliumin both lesions shows predominantly benignreactive changes. In 4 (0.8%) patients, potentially malignantchanges (atypical hyperplasia) were noted in thecovering epithelium, but there were no data on malignantalteration [177, 226].The treatment of choice for VCPs is microlaryngoscopicsurgical removal. Childhood VCNs may disappearin puberty. Small incipient VCNs in adults may alsovanish spontaneously or after voice rehabilitation . Surgicalintervention is indicated when there is no improvementafter conservative treatment.7.5.2 Contact Ulcerand Granuloma,Intubation GranulomaContact ulcer (CU), granuloma (CG) and intubationgranuloma (IG) are benign, inflammatory, exophytic orulcerative lesions, usually located in the posterior thirdof the glottic area. Aetiologically, the lesions arise inresponse to various mechanical and chemical injuries,such as voice abuse or protracted forceful coughing, acidregurgitation and intubation injuries. They display similarsymptomatology and clinical appearance, and moreor less identical histopathological features and prognosis[16, 28, 77, 177, 180, 374, 383, 384].Excessive shouting or coughing cause repeated microtraumasof the thin mucosa of the vocal cord processes.They strike each other in phonatory adductionof the arytenoids, which leads to the development of ulcerativeor exophytic lesions of one or both vocal cords[384]. Additionally, acid regurgitation due to hiatal herniaor gastritis may cause the same type of lesions in theposterior glottic area.Intubation granuloma is an undesired sequel of intubationtube pressure during anaesthesia or intensivecare treatment.Intubation granulomas are more common in females,while hyperacidic granulomas and CU/CGs are predominantin males [104, 177, 180, 383].Clinically, ulceration or exophytic lesions can befound, mono- or multilobular, frequently bilateral, measuringup to 15 mm in diameter, that range from palegrey to dark red, sometimes with an ulcerated surface(Fig. 7.7a) . Hoarseness , the sensation of a foreign body ,coughing , a sticking sensation , pain in the throat, andthe feeling of acidity, are the prevailing symptoms in allthree types of lesions .Histologically, an ulceration of the posterior mucosa,covered by necrotic tissue and fibrin, is initially seen.