Vocal Fold Granuloma: Unresolved Issues

Key Glossary Terms

Vocal Fold Granuloma
Pale, sometimes red, mass on vocal folds resulting from irritation; contains inflammatory cells, new blood vessels; usually found over arytenoid cartilages at the site of contact during vocal fold closure

Vocal Folds
Also known as vocal cords; a pair of muscular ligaments in the voice box (larynx) which vibrate to produce sound

Arytenoid Cartilages
Pair of pyramid-shaped cartilages to which the vocal folds are attached in the back of the voice box; spaced well apart for normal breathing; come together for sound production

Glossary

Proton pump inhibitors (PPIs) are the main class of medications used to treat backflow of stomach fluids to the voice box (laryngopharyngeal reflux). The optimal length of time for taking PPIs before surgery is performed remains to be established. Decisions should be made on a case-by-case basis. (For more information, see Reflux Laryngitis.)

Voice therapy is used to treat vocal misuse or abuse. Some otolaryngologists question the effectiveness of voice therapy in the treatment of granulomas, while others debate how long this therapy should be used before other treatments are introduced.

While laser-based resection is sometimes preferred since its intense heat prevents the bleeding common in knife-based excision, it can damage tissue and lead to scarring. "Cold steel" knife-based surgical resection is usually preferred because the risk for scar tissue formation at the surgical site is lower.

Because injections of botulinum toxin, type A cause vocal fold immobility, they can increase the severity of hoarseness and other vocal symptoms. Both patient and physician must consider potential risks and benefits of botulinum toxin, type A injections to help granuloma(s) heal.

Steroids are used to reduce inflammation. Steroid therapy of vocal fold granuloma is controversial for two main reasons.

1. No conclusive evidence exists indicating that steroids benefit individuals with granulomas.
2. There is some disagreement about how steroids should be prescribed – via topical inhalant, pill, or injection. In particular, topically applied and injected steroids have the benefit of affecting a specific area of the vocal fold, while pill-based steroids have a more systemic effect throughout the body.

NOTE: Most patients find that the inhaled steroids are very irritating to the throat and may therefore be detrimental to the treatment of vocal fold granulomas.

Furthermore, the question as to when to prescribe steroids remains unanswered. Some otolaryngologists believe these medications should be used early on in the treatment of granulomas, whereas others feel treatment for underlying causes (such as anti-reflux therapy or voice therapy) should be used first.