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Granuloma

Granuloma

What is a granuloma?

A granuloma is a benign  growth that results from irritation or trauma. It is usually found at the back of the vocal fold, over a part of cartilage called the vocal process which lies just underneath the membrane covering the larynx. Because there is little overlying soft tissue for cushioning, it is prone to trauma from impact with the vocal process of the opposite vocal fold when the folds come together. This happens during regular speaking, and even more forcefully during loud speaking or singing, throat-clearing, and coughing.

granuloma-1

Figure 1A &B: A granuloma is growing over the vocal process of the vocal fold. Somewhat hidden during voicing (left), it is obvious when the vocal folds open (right). The location shows how the area is traumatized when the vocal folds come into contact.

The area around the vocal process may also become irritated from the breathing tube routinely placed through the vocal folds during general anesthesia. This creates a special type of granuloma known as an intubation granuloma, which tends to grow in the days and weeks after the general anesthetic. Because these are not related to voice behavior, they are generally less stubborn than granulomas that arise spontaneously.

There is very good evidence that laryngopharyngeal reflux, an important source of irritation in the larynx, contributes significantly to the formation of a granuloma.

What are the symptoms of a granuloma?

Commonly, a granuloma causes a sensation of something in the throat, hoarseness and voice breaks. The first of these symptoms can be especially troublesome, as it is likely to provoke throat clearing or coughing which can worsen the irritation which causes the granuloma in the first place. This gives rise to a cycle of irritation and granuloma formation which can be hard to break.

The location of a granuloma is so characteristic as to be nearly enough to make the diagnosis. Unlike many benign vocal fold growths, a granuloma is not generally found at the midpoint of the vibratory part of the vocal fold. Conversely, nearly all growths found over the vocal process at the back of the vocal fold are granulomas. Polyps do not form here.

Voice symptoms generally result from the mass of the granuloma, which can prevent even closure of the vocal folds necessary for normal voice production. In such a situation, hoarseness is typically breathy, and it is difficult to raise the volume of the voice. Again, a cycle may begin in which a person may try harder and harder to speak loudly, thereby increasing vocal fold trauma and worsening the granuloma. If the granuloma is attached to the vocal fold by a stalk (see figures below), it can flip in and out of the way of the vocal folds and cause intermittent voice breaks rather than out-and-out hoarseness.

granuloma-2

Figure 2A &B: Granulomas are often amenable to medical – as opposed to surgical – management. This bulky left-sided granuloma (left) reduced in size considerably after four weeks of treatment with medication alone (right).

A granuloma is one of the few vocal fold growths that can cause pain. This can be sharp during coughing, swallowing or throat clearing when the granuloma is directly irritated. Occasionally, the pain can be felt in the ear on the side of the mass. This phenomenon is known as “referred pain,” and results from the pattern of sensory nerves in the head and neck.

What does a granuloma look like?

A granuloma is usually a reddish or pale lesion that occurs at the characteristic location over the vocal process. It can resemble a mound of tissue raised from the surrounding mucosa . A granuloma may grow to be quite large, forming a smooth spherical mass as in figures 2 and 3 above. It can be either broad-based or narrow-necked. Sometimes, there is a cleft in the mass created by repeated impact of the edge of the opposite vocal fold.

Granulomas tend to grow until the causes of irritation are addressed. Occasionally a granuloma will become so large that it will outgrow its blood supply and slough off. This is no solution, however, as the factors that caused it in the first place will likely cause another.

Simply removing the granuloma surgically without correcting the irritation that caused it will result in regrowth in the overwhelming majority of cases. In fact, treating the underlying irritation properly generally makes surgery unnecessary, as the granuloma will recede by itself.

How is a granuloma treated?

Aggressive steps to control reflux, including changes in diet and eating behavior as well as anti-acid medication, are always helpful. Often, medication must be taken in high doses, in excess of those recommended for routine control of reflux, and for up to several months. There is no evidence that antibiotics are helpful in most cases.

Voice therapy aimed at correcting behaviors that cause vocal fold trauma, such as habitual loud-talking or throat clearing, is as important as treating reflux. People generally underestimate the effect and importance of such behaviors, and most stubborn cases of granuloma result from poor control of these factors.

Surgery is generally a treatment of last resort, as most granulomas will shrink and eventually disappear with proper medical measures and behavioral changes. Surgical removal can be used in cases where a very large granuloma is likely to take a long time to resolve in order to reduce symptoms while treatment takes effect. Surgery without other treatment results in recurrence of the granuloma in the majority of cases.

Too often, surgical removal is used as a ‘quick fix’ for granulomas, because it is considered to be easier than treating reflux and changing harmful vocal behaviors, both of which require discipline and patience. Surgery is a poor substitute, however, as most granulomas grow back. Determined non-surgical treatment, on the other hand, can avoid the need for surgery altogether.
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