A Royal Pain in the Throat Tinnitus - ENT & Allergy Associates

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Vo c a l Pr o c e s s Gr a n u l o m a :A Ro y a l Pa i n i n th e Th r o a t !C h a n d r a Iv e y, M.D.Chronic throat pain is occasionallycaused by a poorly understood anddifficult to treat problem known asa vocal process granuloma. The symptomsof a vocal process granuloma seem to appear“overnight” then quickly become annoyinglypersistent. Patients are typically first seenby their primary care physician and treatedfor an infectious cause. Weeks later, whenthey are not better, they are referred to anotolaryngologist for evaluation. Patients areoften placed on an anti-reflux regimen andasked to come back in two to four months.When the symptoms continue to persist, theotolaryngologist begins to introduce wordslike “voice abuse”, “BOTOX”, and “surgery”,much to the dismay of the patient.I began to wonder what I could tell thesepatients in order to help them understandthis “chronic” condition that causes them toclear their throats constantly during the day,and to hope that the next time they speakthey will not feel that annoying “tug” in theirneck. More importantly, I began to evaluatewhich therapeutic approach is the most optimalto recommend? In this article, I sharewhat I have learned from my experience.Vocal process granuloma has been calledmany different things throughout history,including “contact ulcer” and “pepticgranuloma” in reference to the possibleetiology of the condition. Traumatic orinflammatory conditions involving thevocal process of the arytenoid cartilage maycause disruption of the epithelium, alongwith ulceration and/or focal deposition ofgranulation tissue (Figure 1). This portion ofthe vocal cord has thin mucoperichondriumand a relatively tenuous blood supply whichputs this area at risk for damage. The useof the word “granuloma,” however, ismisleading, as there are only occasionallymulti-nucleated giant cells present – the cellsthat are pathognomonic for true granulomaformation in mycobacterial infection orsarcoidosis. Instead, histologic analysis of thearea displays granulation tissue in association6with acute and chronic inflammatorycells, angioneogenesis and fibrocytes. Alesion may display a disrupted or ulceratedepithelium under the area of granulation(thus the term contact ulcer) or a thin intactepithelial surface expanded outward withdeposition of granulation underneath (thusthe rounded granuloma) 1 . These histologicabnormalities can be accompanied bysclerotic changes of the arytenoid cartilage,or degenerative chronic perichondritiswithin the cricoarytenoid joint. Thesecartilaginous changes may themselvescontribute to granuloma formation byaltering the joint movement or furtherworsening circulation. These underlyingchanges can also impact treatment, as theycannot be reversed and may contribute torecurrence despite appropriate managementat the mucosal level.Vocal process granuloma most often impactsthe cartilaginous portion (respiratory part)of the true vocal fold more than the membranousportion (vibratory part). Therefore,unless large, patients more commonly complainof throat clearing, globus sensation,cough, odynophonia and odynophagia sincethe granuloma may not disrupt the mucosalwave. However, a change in the quality ofvoice and fatigue while speaking can occasionallyoccur. If the area involved is small,patients may even be asymptomatic. A localizedsensation rather than a general burningor discomfort in the throat also suggestsgranuloma rather than other pathology
(such as LPR or sensory neuropathy). Anaccurate diagnosis is aided by a history ofa recent URI or severe cough, reflux, vocaltrauma/abuse, or recent intubation.The two main hypotheses for pathogenesisof vocal process granuloma – neither ofwhich is likely the full story – are (1) chemicalinjury, and (2) mechanical injury to thesite 2 . Research on chemical injury to the sitehas focused on the role of laryngopharyngealreflux in damaging the tissue of the posteriorglottis. In 1980, Ward et al describedpatients with granuloma as “hard driving,tense people who are likely to be late eaters,heavy drinkers, banquet attendees, andspeakers” 3 . One common thread betweenthese behaviors is the increased likelihood ofacid reflux. When asked, patients will oftengive a history of either having typical heartburnsymptoms or symptoms suggestinglong term reflux, such as globus sensation,chronic cough, throat clearing, and thickmucus. Dual pH probe testing has shownthat pharyngeal reflux is more likely to befound in patients with granuloma; 17 of 26patients with granuloma had positive exams(65%) versus five of 19 controls (26%) 4 . Itwas also found that those subjects with granulomahad more frequent reflux episodes,and that these episodes were predominantlywhile standing, not while lying supine. Perhapsthe most explicit evidence to supporta role for chemical injury was published byDelahunty and Cherry in 1968, where theauthors applied gastric juice to the vocalprocesses of dogs and were able to inducegranuloma formation 5 .While these studies helped to solidify therole of refluxate in the formation of vocalprocess granuloma, otolaryngologists oftensee patients with evidence of severe refluxwithout an accompanying granuloma orulcer. In addition, there are studies thatreveal that treating granulomas with protonpumpinhibitors, even in conjunction withother treatment modalities, is successful inless than 50% of cases 6 . Thus, reflux cannotalways be the primary etiologic factor.Mechanical injury of some kind is thoughtto be necessary for the formation of thislesion. Since the innovation of flexibleendotracheal tubes in the early 20th centuryreports of granuloma formation have beenassociated with their use. Endotrachealtubes are positioned to lie between thecartilaginous larynx and the vocal process.Figure 1: Typical appearance of a vocal processgranuloma.Figure 2a: Intubation granuloma of the right vocalprocess.The resultant pressure is thought to quicklycompromise circulation in the thin mucosacausing erythema and ulceration 7 . Longtermintubation also has the capability ofdisrupting the perichondrium and causingsclerosis of the arytenoid or cricoarytenoidjoint. Damage to the vocal process occursmore frequently after intubation with a largediameter tube, simultaneous nasogastric tubeplacement, and with difficult intubation 8 .Intubation granuloma was shown totypically occur approximately four weekspost-intubation and was more commonin females than males, while granuloma ingeneral was more common in males (Figure2). Other studies claim that intubationassociatedgranulomas tend to have a lowerrecurrence rate, even after surgical excision 6 .Most granuloma formation does not occurin association with intubation. Traumafrom speaking patterns (phonotrauma) orfrom chronic cough is thought to be a morecommon contributor to vocal process lesions.Cough, while some argue as to whether itis the proverbial chicken or egg, leads toplosive apposition of the vocal processes in arepetitive fashion. Regardless of the etiologyof cough (infection, reflux, post-nasal drip,Figure 2b: Resolution of granuloma after voice rest, PPI,and four weeks of inhaled steroids.Figure 3: Vocal cord papilloma with the appearance ofbilateral vocal process granuloma. In diagnostic uncertainty,biopsy is indicated.or the presence of the granuloma itself), itcan cause, maintain, or worsen granuloma.Phonotrauma has been found frequentlyto be associated with these lesions. Thesepatients exhibit monotonous vocal patterns,low fundamental frequency, vocal frye, andlaryngeal hyperfunction (muscle tensiondysphonia and hard vocal stops) 9 . Vocaltherapy techniques that slightly elevatethe fundamental, reduce frye, and reducemonotony in the speaking voice havebeen successful in reducing the size of thegranuloma and the associated symptoms.Visual and sensory feedback techniques thatassist patients in speaking without allowingthe vocal processes to fully AD-duct havealso produced very good results 10 .Since multiple predisposing factors arelikely necessary for granuloma to occur,treatment algorithms must address the twomost significant factors, vocal cord traumaand reflux, or the likelihood for successdecreases substantially. Treatment modalitiesinclude anti-reflux regimens (medical andbehavioral), voice therapy, voice rest, cough7
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