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

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suppression, steroid therapy, Botulinumtoxin A (“BOTOX”) therapy and, finally,surgical excision.Kaufman and colleagues suggest the use ofdouble dose treatment with PPIs (30 minutesprior to breakfast and dinner) 11 . Behavioralmodifications include reduction of certainfoods, including citrus and tomato basedproducts, as well as caffeine, chocolatesand mint. Cessation of eating at least twoto three hours before lying supine helps todecrease refluxate. Kaufman has also recentlydiscussed the role of smoking in promotingrefluxate and has shown pH evidence of acidin the pharynx after smoking (unpublishedGrand Rounds discussion, New York Eye andEar Infirmary). While some studies notedless than 50% improvement in granulomaafter these modifications, this may be dueto inadequate length of treatment; Kaufmannoted that granuloma often took six to eightmonths to resolve – much longer than mostphysicians and patients are tolerant enoughto wait 12 . Often, even after resolution, antirefluxprecautions need to be continued toprevent recurrence of the lesion.Reduction in vocal cord mechanical traumais also imperative for the management ofgranuloma. Months of voice rest used to betraditional treatment for this ailment and oftenproduced good, albeit short-lived, results.Unfortunately, most patients are unable toadequately self-limit their speaking for morethan a few days and are often unable to stoptalking due to the demands of their professions.The voice therapist is a useful assistant,both in terms of vocal retraining exercises,as well as to monitor (i.e., police) vocal8abuse patterns. As previously discussed,some forms of voice therapy have been documentedto reduce the size and symptoms ofgranulomas, and often the retraining of vocalmonotony, frye, and fundamental frequencycan help to decrease recidivism.Vocal retraining may also assist in breakingthe cycle of cough and throat clearingif these behaviors have become habitual.When cough is due to reflux, allergy, andpostnasal drip, treating the underlying etiologyis extremely important and, in myopinion, is one of our most common areasof failure. Aggressively treating allergy andnasal drainage, as well as prescribing inhaledsteroids and cough syrups can significantlyimpact cough and may be performed forshort periods of time. While not advocatedby all laryngologists, inhalant steroids usedin aspirate voice (in order to AD-duct thevocal cords while inhaling the medication)can deposit the anti-inflammatory agent directlyon the larynx. While oral steroid usehas not shown to impact recurrence rate, onegroup showed resolution in 85% of thosewho had received topical steroid for intubationgranuloma versus only 43% of thosewho had not 13,14 . Patients must rinse theirmouths after the use of steroid, and theyshould be evaluated periodically for fungalovergrowth. Intra-lesional steroid injectionis another option that may assist in decreasinggranulation and fibrin production thusassisting in the resolution of the granuloma.The use of BOTOX for treatment of vocalprocess granulomas may be useful in casesthat have not responded to treatment aftereight to twelve months. The main goal ofBOTOX use is to decrease AD-duction,reducing contact trauma between the vocalprocesses for a prolonged period of time(two to three months), allowing for healingand resolution of the granuloma 15 . This canbe performed unilaterally or bilaterally, andit has been used alone or in conjunctionwith conservative surgical excision.Candidates for BOTOX are patients whowere either unable to adequately utilizetheir vocal retraining or may have otherpoor prognosticators for healing, such as asclerotic arytenoid.Surgical excision is rarely used to treat vocalprocess granuloma because the lesion tendsto recur after excision. Some advocateoperative intervention only in cases of airwayobstruction or when diagnostic dilemmais present. Very rarely, papilloma (Figure3), sarcoma, carcinoma, or sarcoid canimitate granuloma 16 . Others contend thatafter failed “conservative” therapy, surgicalintervention for intubation granulomashows less recurrence than those from otheretiologies 6 . If excision is considered, a smallendotracheal tube or a jet ventilator shouldbe considered to minimize surgical trauma.Also, removing granulation without causingfurther trauma to the perichondrium isnecessary. Some feel that this should onlybe performed using a cold-knife techniquesince CO2 laser excision may cause thermalinjury to the surrounding tissue. In-officetrans-oral removal of pedunculated lesions,repeat partial excision of larger lesions,in-office KTP or PDL laser ablation ofthe granuloma, have also been recentlydescribed 17 . These mechanisms couldpotentially cause involution of the lesion bydestroying angioneogenesis supporting thegranulation tissue. It is also important torecognize that pedunculated lesions, withtime, may autoinfarct and be cleared withcough from the airway, leaving a muchsmaller lesion.So what do we tell our patients? Whilesome causes are more straightforward thanothers, curing the disease is never a certainty.Helping the patient understand all of thepossible factors involved in the etiology of– and also the reasons for persistence of –the granuloma can create an ally during thearduous treatment course. Initially settingthe course of therapy at a minimum of sixmonths gives the patient a realistic time framewithin which to evaluate progress. Stressingthe fact that in these cases, surgery (“can’t
you just take it off?!!”) could possibly worsenthe situation, will help the patient come toterms with the multi-modality treatmentthat is recommended (e.g., voice therapy,medication, behavioral modification).With this treatment regimen, studies haveshown that 88% of patients have partial orcomplete resolution of their symptoms, andonly 12%of patients become truly chronic 18 .With time and patience, the proverbial“pain in the throat” doesn’t have to leave abad taste in your mouth.REFERENCES1. Haggit RC. Histopathology of refluxinducedesophageal and supraesophagealinjuries. Am J Med 2000; 108 (Suppl4a):109S-111S.2. Hoffman HT, et al. Vocal processgranuloma. Head and Neck 2001; 23:1061-1074.3. Ward PH et al. Contact ulcers andgranulomas of the larynx: new insights intotheir etiology as a basis for more rationaltreatment. Otolaryngol Head Neck Surg1980; 88:262-269.4. Ylitalo R and Ramel S. Extraesophagealreflux in patients with contact granuloma:a prospective controlled study. Ann OtolRhinol Laryngol 2002; 111(5 Pt 1):441-46.5. Delahunty JE and Cherry J.Experimentally produced vocal cordgranulomas. Laryngoscope 1968; 78:1941-1947.6. Lemos EM, et al. Vocal process granuloma:clinical characterization, treatment andevolution. Rev Bras Otorrinolaringol 2005;71:494-498.7. Jackson C. Contact ulcer granulomaand other laryngeal complications ofendotracheal anesthesia. Anesthesiology1953; 14:425-436.8. Santos PM, Afrassiabi A, and WeymullerEA Jr. Risk factors associated with prolongedintubation and laryngeal injury. OtolaryngolHead Neck Surg 1994; 111(4):453-459.9. Ylitalo R, and Hammarberg B. Vocecharacteristics, effects of voice therapy, andlong-tern follow-up of contact granulomapatients. J Voice 2000;14(4):557-566.10. Leonard R, and Kendall K. Effects ofvoice therapy of vocal process granuloma:a phonoscopic approach. Am J OtolaryngolHead Neck Surg 2005; 26:101-107.11. Zeitels SM et al. Management ofcommon voice problems: Committeereport. Otolaryngol Head Neck Surg 2002;126(4):333-348.12. Koufman JA. Contact ulcer andgranuloma of the larynx. Curr TherOtolaryngol Head Neck Surg 1994; 5:456-459.13. Jaroma M, Pakareinen L, and NuuteinenJ. Treatment of vocal cord granuloma. ActaOtolaryngol 1989; 107:296-299.14. Roh HJ et al. Topical inhalant steroid(Budesonide, Pulmicort Nasal) therapy inintubation granuloma. J Laryngol Otol1999; 113(5):427-432.15. Nasri S et al. Treatment of vocal foldgranuloma using boulinum toxin type A.Laryngoscope 1995; 105:585-588.16. Devaney KO, Rinaldo A, and FerlitoA. Vocal process granuloma of the larynx—recognition, differential diagnosis andtreatment. Oral Oncology 2005; 41:666-669.17. Clyne SB et al. Pulsed dye laser treatmentof laryngeal granulomas. Ann Otol RhinolLaryngol 2005; 114:198-201.18. Emami AJ et al. Treatment of laryngealcontact ulcers and granulomas: a 12-year retrospective analysis. J Voice 1999;13(4):612-617. •9
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