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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. | |||
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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. |
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Unlike many must 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. |
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| 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 2 and 3), it can flip in and out of the way of the vocal folds and cause intermittent voice breaks rather than out-and-out hoarseness. | |||
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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. |
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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. |
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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. |
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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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2009 Voice Medicine