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
Also known as vocal cords; a pair of muscular ligaments in the voice box (larynx) which vibrate to produce sound
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
Any type of vocal fold growth or lesion requires active intervention when it causes progressive or persistent symptoms. Intervention is especially required when a possibility of cancer exists. If cancer has been ruled out and identification of a vocal fold granuloma is made, a treatment plan consisting of two basic parts is begun.
First-line treatments of underlying cause(s) of granuloma formation
Additional treatments for non-responsive granulomas
1. First Line Treatment of Underlying Cause(s)
A variety of irritants or traumas to the larynx can result in a granuloma. Fortunately, many of the causes of granuloma can be successfully treated by removing the source of the irritation.
In particular, granulomas caused by backflow of stomach fluids to the voice box (laryngopharyngeal reflux or LPR) or by trauma from forceful contact of vocal folds during vocal misuse or overuse, respond favorably to non-surgical therapy, described in the table below.
Treating the Underlying Causes of Granuloma
Goal of Treatment
Breathing Tube-Related Granulomas
Caused by irritation from breathing tube
Discontinue breathing tube when no longer needed
Minimize irritation when breathing tube needed
Observation once breathing tube is removed
Observation and breathing tube adjustments – when continued use needed
Check for reflux
Caused by backflow of stomach fluids to voice box (laryngopharyngeal reflux or LPR)
Stop stomach acid reflux from irritating the vocal folds
Treatment for laryngopharyngeal reflux typically involves the use of medications that decrease the amount of acid released by the stomach (proton-pump inhibitors) and concurrent lifestyle precautions against reflux. (For more information, see Reflux Laryngitis.)
Vocal Use-Related Granulomas
Caused by forceful contact during vocal misuse/abuse
Stop unnecessary forceful contact of the vocal folds against one another from vocal misuse or harmful vocal habits
Voice therapy is often prescribed to help modify vocal use patterns that damage the vocal folds. (For more information, see Voice Therapy.)
A Note on Multifactorial Causes of Vocal Fold Granuloma
Since vocal abuse and reflux may both contribute to granuloma formation, simultaneous combination therapy may be necessary – both voice therapy and anti-reflux medications and lifestyle precautions.
Voice therapy aims to:
Help patients reduce excessive contraction or squeezing of the voice box muscles used to speak
Train patients to use proper breath support to produce an appropriate voice without excessive effort
Though noticeable improvement will usually be evident after only four to six weeks of LPR treatment and voice therapy, granuloma symptoms (and the lesion) may take several months to fully resolve.
Non-Response to Treatment – Need to Revisit Diagnosis
In approximately 15 to 20 percent of the patients, a granuloma(s) will continue to grow or cause symptoms despite six to eight weeks of appropriate speech/voice therapy and/or control of backflow of stomach fluids (reflux). Vocal fold granulomas that do not respond to anti-reflux medication or voice therapy should prompt re-analysis since another lesion type might be present rather than a granuloma. This may need additional testing.
There are a number of different vocal fold abnormalities that are similar in appearance to granuloma. In particular, the lesion types listed below are sometimes confused with granuloma and should be considered when initial treatment of the underlying cause of granuloma is unsuccessful in reducing the size of the granuloma.
Laryngeal cancer: Malignant growths occurring on or near the vocal folds
Non-cancerous growths: Polyps, cysts, or other lesions (For more information, see Vocal Fold Nodules, Polyps, Cysts, and Reactive Lesions.)
Papillomas: Abnormal growths in response to infection by the human papilloma virus (For more information, see RRP-Papillomatosis.)
Uncommon infections: These include tuberculosis, fungal infections, sarcoidosis, Wegener’s granulomatous, and amyloidosis
Consideration of Cancer
If and when cancer is suspected, granulomas should be surgically removed and the specimen analyzed by a pathologist for possible cancer (excisional biopsy).
False Negative Result
Failing to obtain an adequate tissue sample during biopsy may incorrectly suggest that cancer is not present.
A biopsy may be necessary to further investigate growths or masses. Biopsies are usually performed as an outpatient procedure in the operating room under general anesthesia. With the aid of a microscope, a lesion can either be removed entirely, or sampled and sent to a pathologist for further analysis. By examining the lesion (or sample) at even greater magnification, the pathologist can detect microscopic characteristics and give a conclusive diagnosis as to whether cancer is present.
In reassessing lesion identification, it is important to determine if the failure of voice therapy and anti-reflux medication was not due to inadequate therapy or poor patient follow-up or compliance.
Additionally, other tests investigating backflow of stomach fluids may be performed, including barium swallow esophagram and/or a 24-hour double-probe pH monitoring. (For more information, see Reflux Laryngitis.)
If the biopsy reveals that only a granuloma is present, treatment will need to be more intensive and last longer, and additional treatments may be added.
2. Additional Treatments for Granulomas That Are Not Treated by First-Line Treatments
For unresponsive vocal fold granulomas, additional treatments are indicated.
Surgical removal of the granuloma is indicated for granulomas non-responsive to first-line treatments and/or when patient profession or lifestyle requires more aggressive treatment. Removal of the granuloma is done by phonomicrosurgical techniques with preservation of voice function in addition to removal of the granuloma as a key goal of the procedure. The surgically removed specimen is then examined by a pathologist for cellular structure and composition – corroborating the diagnosis of granuloma or determining if cancer might also be present. (For more information, see Phonomicrosurgery.)
Medical Formulation of Botulinum Toxin, Type A Injections
Physicians have recently begun using a medical formulation of botulinum toxin, type A to treat vocal fold granulomas caused by overly forceful contact from vocal misuse or overuse. Botulinum toxin, type A, is injected into the muscle of the vocal fold to temporarily limit its mobility and thus decrease injury from forceful contact of vocal folds during voice misuse. This then leads to a decrease in irritation and inflammation allowing the granuloma to heal, as well as prevent new granuloma formation. Since the effects of botulinum toxin, type A injections are short-lasting (three to five months), they sometimes must be performed several times to achieve a desired result.
Injections of medical formulation of botulinum toxin, type A, for granuloma should be performed by a skilled otolaryngologist. (For more information, see Voice Care Team and Spasmodic Dysphonia.)
Adequate First-Line Treatment Is Necessary
Unless cancer or infection are present or suspected, first-line non-surgical treatment should be given optimally – proper medicine and dosage, duration of treatment, patient compliance and follow-up, lifestyle changes and precautions, and effective voice therapy programs.
Treatment of Other Contributing Causes
If there are multiple causes contributing to granuloma formation, treatment of all causes is necessary.
Treatment of Cause(s) Necessary for Long-Term Control
Even if the vocal fold granuloma is removed completely by surgery, granuloma formation will recur if the underlying cause(s) are not treated.
Overly Aggressive Surgery
Aggressive surgery can further disturb the vocal folds or the arytenoid cartilages, predisposing patients to a recurrence of granulomas.
Patient education material presented here does not substitute for medical consultation or examination, nor is this material intended to provide advice on the medical treatment appropriate to any specific circumstances.