Contact Ulcer and Granuloma

Author Credentials 

Laura M. Dominguez, MD
7703 Floyd Curl Dr, MSC 7777
San Antonio, Tx 78229
Email: DominguezL@uthscsa.edu

Module Summary

Vocal process granuloma/ contact ulcers are diagnosed based on clinical criteria using fiberoptic laryngoscopy.  These lesions are initiated by injury to the mucosal lining over the vocal process by endotracheal intubation or phonotrauma, and are perpetuated by active laryngopharyngeal reflux disease.  Successful treatment involves aggressive anti-reflux treatment with PPIs, inhaled corticosteroids, and in some cases speech therapy and/or vocal fold augmentation.  Full resolution of these lesions may take months, especially in the case of non-intubation granulomas. Surgical treatment of these lesions may be indicated if malignancy is suspected or impending airway obstruction is present.

Module Learning Objectives 
  1. Explain the risk factors for the development of contact ulcers and vocal process granulomas (VPGs).
  2. Confidently identify VPGs with the appropriate diagnostic evaluation. 
  3. Review the appropriate treatment algorithm for VPGs.

Anatomy

Learning Objectives 
  1. Identify the most common location of contact ulcer and granuloma formation.
    1. Vocal process
  2. Describe the underlying anatomy that makes this location susceptible to injury.
    1. Thin layer of mucosa and underlying perichondrium covers this portion of the arytenoid
    2. Area of high pressure contact zone between vocal folds during hard glottal attacks
       
References 
  1. Shoffel-Havakuk H, Halperin D, Yosef L, Feldberg E, Lahav Y. Lesions of the posterior glottis: clinical and pathologic considerations and treatment outcomes. J Voice. 2014; 28(2):263.e1-263.e8.

Pathogenesis

Learning Objectives 
  1. Discuss the potential etiologies of VPGs
    1. Iatrogenic trauma
      1. Endotracheal intubation
    2. Phonotrauma
      1. Chronic cough
      2. Throat clearing
      3. Vocal abuse/ misuse
    3. Laryngopharyngeal reflux
    4. Glottic insufficiency
       
References 
  1. Shoffel-Havakuk H, Halperin D, Yosef L, Feldberg E, Lahav Y. Lesions of the posterior glottis: clinical and pathologic considerations and treatment outcomes. J Voice. 2014; 28(2):263.e1-263.e8.
  2. Carroll TL, Gartner-Schmidt J, Statham MM, Rosen CA. Vocal process granuloma and glottal insufficiency: an overlooked etiology? Laryngoscope. 2010; 120(1):114-20. 
     

Basic Science

Learning Objectives 

Understand the patterns of laryngeal tissue injury as they relate to acid and pepsin.

References 
  1. Bulmer DM, Ali MS, Brownlee IA, Dettmar PW, Pearson JP. Laryngeal mucosa: its susceptibility to damage by acid and pepsin. Laryngoscope. 2010;120(4)777-82. 

Incidence

Learning Objectives 
  1. Identify potential correlation between gender and VPG etiology
    1. Males- LPR
    2. Females- intubation
  2. Recognize the potentially high recurrence rate
    1. Up to 92% reported
References 
  1. Lemos EM, Sennes LU, Tsuji DH. Vocal process granuloma: clinical characterization, treatment and evolution. Braz J Otorhinolaryngol. 2005;71(4):494-8. 
  2. Karkos PD, George M, Van Der Jeen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol. 2014;123(5):314-20. 

Patient Evaluation

Learning Objectives 
  1. Recognize some of the common presenting symptoms
    1. Odynophonia/Laryngeal pain
    2. Globus
    3. Dysphonia
    4. Dyspnea
    5. Hemoptysis
  2. Recall risk factors for VPG formation (see etiology)
  3. Describe the typical appearance of contact ulcers and VPGs
    1. Contact ulcer
      1. Shallow ulceration over vocal process with heaped up white borders, appearance of a “crater”
    2. VPG
      1. Pink/red smooth spherical mass at vocal process
      2. Unilobed or bilobed
  4. Identify exam findings of other potential etiologies
    1. LPR
      1. Arytenoid and interarytenoid erythema/edema
      2. Pseudosulcus
    2. Glottic insufficiency
      1. Vocal fold motion impairment on stroboscopy
      2. Vocal fold atrophy
References 
  1. Lemos EM, Sennes LU, Tsuji DH. Vocal process granuloma: clinical characterization, treatment and evolution. Braz J Otorhinolaryngol. 2005;71(4):494-8.
  2. Carroll TL, Gartner-Schmidt J, Statham MM, Rosen CA. Vocal process granuloma and glottal insufficiency: an overlooked etiology? Laryngoscope. 2010; 120(1):114-20.

Measurement of Functional Status

Learning Objectives 
  1. Recognize the possible utility of laryngeal function studies in diagnosing related conditions. 
    1. Glottic insufficiency
    2. Muscle tension dysphonia

Pathology

Learning Objectives 
  1. Describe the typical pathologic findings of VPGs.
    1. Non-specific granulation tissue
    2. Hyperplastic squamous epithelium
References 
  1. Shoffel-Havakuk H, Halperin D, Yosef L, Feldberg E, Lahav Y. Lesions of the posterior glottis: clinical and pathologic considerations and treatment outcomes. J Voice. 2014; 28(2):263.e1-263.e8.

Treatment

Learning Objectives 
  1. Understand the potential effect of voice therapy on VPGs.
    1. Vocal misuse/ abuse
    2. Throat clearing
References 
  1. Leonard R, Kendall K. Effects of voice therapy on vocal process granuloma: a phonoscopic approach. Am J Otolaryngol. 2005;26(2):101-7.

Medical Therapies

Learning Objectives 
  1. Recognize the different medications that can be prescribed to help treat VPGs.
    1. Acid suppression therapy
    2. Inhaled corticosteroids
References 
  1. Karkos PD, George M, Van Der Jeen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol 2014;123(5):314-20.

Surgical Therapies

Learning Objectives 
  1. Know the indications for surgical treatment of VPGs
  2. Identify the different surgical and procedural interventions that are available for treatment of these lesions. 
    1. Intra-lesional steroid injection
    2. Botulinum toxin injection
    3. Surgical excision
    4. Laser ablation
References 
  1. Karkos PD, George M, Van Der Jeen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol. 2014;123(5):314-20. 

Case Studies

  1. A 21 year-old female with a 5 day history of intubation with an 8.0 endotracheal tube after an asthma exacerbation presents to your office with complaints of severe dysphonia and dyspnea at rest. What examination would you perform and what findings might you expect to see?  
  2. A 35 year-old male with a non-intubation related vocal process granuloma with associated globus and pain is treated for 9 months with bid PPIs and nighttime H2 blockers, as well as speech therapy without resolution.  The granuloma is 5 mm is size, and is smooth and benign-appearing. What treatment would you offer the patient?

Complications

Learning Objectives 

Recognize the potentially high recurrence rate.

References 
  1. Karkos PD, George M, Van Der Jeen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol 2014;123(5):314-20. 

Review

Review Questions 
  1. What is the one common physical exam characteristic of contact ulcers and vocal fold granulomas?
  2. Which patients are more susceptible to intubation-related vocal process granulomas?
  3. What medication is recommended for the treatment of granulomas?
  4. What are the indications for surgical intervention in granuloma?