LaryngoSCOPE Robert T. Sataloff, M.D., D.M.A. Laryngeal Granulomas

Yolanda D. Heman-Ackah and Robert T. Sataloff

Laryngeal granulomas are be- CAUSE OF LARYNGEAL fer from it or by many doctors who nign (noncancerous) masses that GRANULOMAS are not otolaryngologists, because usually occur on the vocal processes when most physicians refer to reflux, of the arytenoids.1,2 The arytenoids Granulomas are masses that de- which is the regurgitation of acid and are cartilages of the larynx (the voice velop as a result of chronic irritation enzymes from the stomach into the box) to which many of the muscles and inflammation of the area that esophagus (the swallowing tube), the that move the vocal folds attach. The forms them. The source of the irrita- pharynx (the throat), or the larynx, part of the arytenoid to which the tion can be from chronic reflux of they associate it with the feeling of vocal fold attaches is called the gastric juices from the stomach onto heartburn. Heartburn may occur vocal process. Granulomas also can the larynx (laryngopharyngeal re- with reflux of a significant amount of occur in other regions of the larynx, flux), from the placement of a breath- acid into the esophagus. However, including the portion of the larynx ing tube through the larynx (intuba- the esophagus is much more resilient above the vocal folds (referred to as tion), from direct trauma to the to the presence of small amounts of the supraglottic larynx), the portion larynx, or from repeated forceful gastric juice, which consists of both of the larynx below the vocal folds contractions of the muscles of the lar- stomach acid and stomach enzymes, (referred to as the subglottic ynx during talking, singing, yelling, than is the larynx, and heartburn 3 larynx), and on the portions of the or coughing (vocal misuse or abuse). may not occur with small episodes of vocal folds that vibrate during reflux. Furthermore, when the phonation (referred to as the Laryngopharyngeal Reflux esophagus is exposed to even large musculomembranous vocal fold). Laryngopharyngeal reflux is not amounts of acid for months or years, often recognized by persons who suf- ϑουρναλ οφ Σινγινγ, Μαψ/ϑυνε 2002 ςολυμε 58, Νο. 5, ππ. 419 − 428 Χοπψριγητ 2002 Νατιοναλ Ασσοχιατιον οφ Τε αχηερσ οφ Σινγινγ Yolanda D. Heman-Ackah and Robert T. Sataloff it may become less sensitive, and the from the dilation and increased num- intubation. Patients usually require sensation of heartburn may disap- ber of local blood vessels that form to intubation for artificial ventilation pear.4 Unlike the larynx, the esopha- help the body bring nutrients to the when they are unable to breathe ade- gus also has a mechanism for protect- injured area. Edema occurs as fluids quately on their own or when they ing itself from the stomach acids. are released from the blood vessels in undergo general anesthesia for The mucosa (the lining tissue) the healing process. Pachydermia surgery. The movement of the endo- of the larynx is much more sensitive laryngeus is the larynx's way of tracheal tube during swallowing or to small amounts of acid and reacts protecting itself from repeated injury. during each breath that the machine more than the esophagus to less ex- By producing multiple layers of makes for the patient can cause irri- posure. Often, the only symptoms of mucosa, the tissue underneath the tation of the portion of the airway laryngopharyngeal reflux are the new layers is protected from the against which the tube is touching, presence of a throat tickle, chronic injuring agent, which in the case of which can be either the part of the throat clearing, the sensation of reflux is acid. A granuloma is the airway that is providing the greatest phlegm in the throat, bad breath, result of the formation of an support for the tube or the narrowest chronic cough, and/or the sensation excessive amount of tissue to protect portion of the airway. Because most that something is stuck in the throat. the area from trauma. Ulceration patients are lying on their backs There may be only one of these occurs when the body is unable to when they are being ventilated, the symptoms, or there may be several of produce multiple layers of mucosa force of gravity pulls the tube against them present at one time. Each of fast enough to overcome the injury. the posterior larynx and the vocal these symptoms is related to the irri- Each time the tissue is injured, it process, causing irritation there. In tation that the acid causes as it con- dies and sloughs away, leaving a children, the site of the greatest irri- tacts the delicate laryngeal mucosa. crater or ulcer. Typically, isolated tation is the subglottic larynx be- Unlike the reflux that causes esopha- erythema and/or edema are signs of cause it is the narrowest part of their geal problems, reflux laryngitis may early and mild forms of laryn- airways. In other patients, the nar- not occur persistently throughout the gopharyngeal reflux. The presence of rowest part of the airway may be the day. pachydermia laryngeus, granuloma, musculomembranous portion of the There are characteristic changes and/or ulceration indicates more vocal fold or the supraglottic larynx. in the larynx that commonly are chronic and severe forms of laryn- The chronic irritation from move- caused by reflux. Chronic irritation gopharyngeal reflux. Laryngopha- ment of the tube results in inflamma- of the larynx by stomach acid causes ryngeal reflux alone can cause the tion. This inflammation can take the chronic inflammation of the posteri- formation of granulomas, but more form of mild erythema, edema, ulcer- or larynx, which is the part of the lar- commonly, reflux contributes to the ation, or granuloma formation. The ynx closest to the opening of the formation of granulomas in concert inflammation that results can hap- esophagus. This inflammation may with other traumatic insults to the pen soon after the endotracheal tube take the form of a granuloma, which larynx, such as intubation, laryngeal is placed or can happen several is a chronic inflammatory lesion trauma, vocal abuse (yelling, scream- weeks later. There is no way to pre- much like the scab that forms on a ing, or severe coughing), or vocal dict which patients will have a signif- wound that is irritated chronically. misuse.1,3 icant inflammatory reaction and Alternatively, the inflammation may which patients will have a complete- present as erythema (redness), ede- Endotracheal Intubation ly uneventful period of intubation, ma (swelling), pachydermia laryn- Granulomas can form from irri- but the presence of reflux laryngitis geus (thickening of the mucosa), or tation caused by contact with an en- appears to be the most important risk ulceration of the posterior—and oc- factor. 3 5 dotracheal tube. These tubes are casionally the entire-larynx. ' Each placed in the glottis, which is the of these is an inflammatory lesion. opening between the vocal folds, and Laryngeal Trauma Inflammation is the body's way of into the trachea (the windpipe) Granulomas can form as a result healing itself. Erythema results when patients need artificial ventila- of direct trauma to the larynx.1,3 La- tion, a process termed endotracheal

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ryngeal trauma can result in granulo- cosal hemorrhage, which is bleeding respiratory tract infection such as a ma formation because the trauma of- within the tissues, may occur in the cold, laryngitis, or mild weakness of ten incites an inflammatory reaction. region of the striking zone. The irri- one or both vocal folds (paresis). The Many situations can result in laryn- tation of the cartilages of the two vo- affected person tries to compensate geal trauma. If an endotracheal tube cal processes hitting each other may for a hoarse or painful voice during is placed in an emergency situation, result in an abrasion. the illness and incorporates new be- the force used to place the tube may After such an episode, hoarse- haviors into his or her routine 6 7 cause injury to the lining tissues of ness or pain in the throat may ac- speech. ' In singers and actors with- the larynx. Similarly, accidental re- company talking and/or swallowing. out formal voice training, abnormal moval of the endotracheal tube can The affected person may inadver- laryngeal muscle tension may devel- injure the lining tissues of the larynx tently adopt new ways of talking op from singing and/or acting.6,7 as the tube is pulled out. Blows to the that initially may alleviate some of More commonly, those with formal neck can cause blunt laryngeal trau- the pain or hoarseness. Often, this voice training may not remember to ma, and penetrating injuries, such as change involves increasing the ten- use their training during "normal" gunshot or stab wounds, can cause sion in some of the muscles of the speaking, and they can develop direct tissue trauma in the larynx. larynx or in some of the accessory problems related to vocal misuse 6 7 Additionally, any surgery or endo- muscles of phonation to produce a during noinial conversation. ' In scopic procedure that involves ma- more audible sound, a condition re- instances of vocal misuse that result nipulation of or around laryngeal ferred to as muscle tension dyspho- in granulomas, the mechanism is the tissue may cause trauma. Each of nia. This new way of talking may same as in patients with vocal abuse; these forms of trauma can result in become an everyday habit of speak- but the chronic irritation from injury to the lining tissues of the ing. The persistent tension in the forceful closure of the vocal folds larynx, thus stimulating an muscles with phonating creates a happens over a longer period of inflammatory re-action that can chronic state of increased forceful time. result in the formation of closing of the vocal folds, resulting granulomas. in chronic trauma and irritation of SYMPTOMS the vocal processes and the striking Vocal Abuse and Misuse zone. This irritation causes chronic Granulomas can cause a variety Granulomas can form in pa- inflammation, which may evolve to of symptoms, and sometimes may tients who abuse or misuse their voic- form a granuloma on the vocal 3 cause no symptoms at all. If the gran- es chronically. Yelling, screaming, process, or nodules (thickened scar- uloma is in a location on the vocal and forceful coughing are forms of like masses), cysts (fluid filled sacs), process or the vocal fold that inter- vocal abuse. Vocal misuse can occur or polyps (soft, inflammatory mass- feres with complete closure or the with incorrect or excessive singing, es) in the striking zones of the vocal normal mobility of the mucosal cover talking, or acting. When a person folds.6 7 ' of the vocal folds, then hoarseness yells, screams, or coughs severely, the In vocal misuse, the affected will be present. This hoarseness is vocal folds are brought together person has a pattern of speaking or perceived as a harsh sounding voice forcefully with a significant amount singing that results in increased ten- if the mobility of the mucosal mem- of contraction of the muscles in the sion in the muscles of the larynx brane is affected. A breathy quality larynx and neck. The vocal folds with voice production. Some people to the voice is perceived if the vocal slam against each other with a have spoken with increased muscle folds do not close completely. When greater force than occurs with nor- tension in their larynges for most of the granuloma is in a position that mal phonation, and trauma occurs in their lives. Others may develop an prevents the vocal folds from closing the portions of the vocal fold that re- abnormal vocal pattern that results completely with normal effort, a ceive the most force, the "striking in increased laryngeal muscle ten- greater degree of force is needed to zone" (the middle one-third of the sion after suffering a change in the bring the vocal folds together, and a musculomembranous vocal fold) and larynx, most commonly an upper the vocal process. As a result, greater force is needed to push air submu-

Μαψ/ϑυνε 2002 421 Yolanda D. Heman-Ackah and Robert T. Sataloff from the lungs through the vocal tion, they can continue to get bigger, cians see the patient to evaluate the folds to create sound. Over the if they remain untreated and exposed cause of the symptoms described course of a conversation or the to repeated trauma. Rarely, they can above. The physician may ask the pa- course of the day, these attempts at grow to a size that is large enough to tient many questions about the compensation can become tiring, reduce significantly the amount of symptoms to help exclude other pos- both physically and vocally. The per- air that is able to go through the lar- sible causes and to help narrow the son who is affected in this way ynx and into the trachea and lungs.8 potential list of problems. usually complains that the voice This airway obstruction may cause After the physician has complet- fatigues easily or that a lot of energy symptoms of shortness of breath at ed taking a history of the patient's is needed to create a loud voice. rest or with exertion. If the inflam- problems, he or she will examine the The inflammation that causes mation causes a break in one of the patient. The physical examination the formation of granulomas may small blood vessels underneath it, will include a complete evaluation of cause irritation of the nerve endings blood may be coughed up. This oc- all of the structures of the head and underneath. This irritation of the curs rarely with granulomas and neck. This complete examination is nerve endings may result in the sen- more often is a sign of a more serious performed because there are some ill- sation of pain, either constantly or illness. A granuloma that sits in a lo- nesses that affect many different re- with eating, talking, or singing, de- cation in the larynx that does not af- gions of the head and neck, and they pending on the proximity of the fect the vocal folds, does not obstruct all should be assessed. In patients nerves to the inflamed area. The pain the airway, and does not irritate the with granulomas, the examination of may be perceived as throat or ear dis- nerve endings may not cause any each of these regions should be nor- comfort. Ear pain occurs because of a symptoms at all. mal unless another illness is also pre- phenomenon called "referred pain." When symptoms do occur, the sent, with the exception of examina- The same nerves that sense problems onset may be sudden or gradual, de- tion of the larynx and possibly the in the throat also sense problems in pending upon the reason the granu- hypopharynx (the portion of the the ear. For unknown reasons, when loma is formed and how fast it en- throat behind the larynx and above the nerves relay information from larges. Sudden development of the esophagus). the throat to the brain, the brain may symptoms is associated with trau- Examination of the larynx and interpret the signal as pain coming matic events such as yelling, scream- the hypopharynx may be performed from the ear. The individual then ing, severe coughing, or intubation initially with a light and mirror. The perceives that he or she is having during surgery or a hospitalization. mirror is often warmed first with wa- pain in the ear. The irritation of the Gradual development of symptoms is ter, a flame, or heated beads to pre- nerve endings may also result in the seen after an upper respiratory tract vent it from fogging during the sensation of a lump in the throat, the infection, with vocal misuse, and examination. The tongue is held sensation that something is stuck in when laryngopharyngeal reflux is the forward, and the mirror is placed the throat, the sensation of a chronic sole cause. The symptoms that one into the mouth and positioned above tickle with or without chronic cough, experiences from granulomas are the back of the tongue to permit or the persistent sensation that the fairly persistent. Occasionally, the adequate visualization of the larynx. throat needs to be cleared.5,8 The ex- symptoms may fluctuate depending On examination with the mirror, the act sensations that any individual ex- upon changes in edema of the vocal physician may see the granuloma in periences depend on which nerve folds. However, they rarely resolve the larynx. The granuloma will endings are affected and how much ir- completely without treatment.1,3,5,8 appear to be a smooth, flesh-colored ritation they are experiencing. Be- mass that may be pedunculated (on cause of individual differences in the a stalk) or sessile (broad-based) and way our bodies are made, the same de- PHYSICAL EXAMINATION may be associated with surrounding gree of inflammation may cause dif- erythema and ulceration. Changes in ferent symptoms in different people. The diagnosis of granulomas is the posterior larynx and Because granulomas are the re- made by a laryngologist or an oto- hypopharynx associated with reflux, sult of an intense inflammatory laryngologist. Typically, these physi as previously described, may also be reac- seen. Because subtleties 422 LaryngoSCOPE

in detail are difficult to assess with the base of the tongue forward so she is certain that the lesion visual- mirror examination, if an abnormal that the larynx can be viewed more ized is a granuloma. This decision is lesion is found, the otolaryngologist easily. Occasionally, a sensation of usually based on the otolaryngolo- will almost always perform either gagging is experienced during the ex- gist's previous experiences with la- flexible or rigid laryngoscopy, or both, amination; otherwise the examina- ryngeal granulomas and other laryn- for better identification of the lesion. tion does not cause much discomfort. geal masses and on the appearance of The choice of instrumentation is This magnified view of the granulo- the patient's lesion. The history that based on the physician's preference. ma can give the physician clues as to the otolaryngologist obtains from the A flexible laryngoscope is a whether the mass is truly a granulo- patient also helps him or her to de- thin, lighted flexible telescope that is ma or whether it is another type of cide on the likelihood of the lesion placed through the nose and into the lesion, such as a cancer, polyp, or pa- being a granuloma or another lesion. throat and usually does not cause pilloma. Each of these lesions has In general, most people with granulo- pain, although it may cause a slight characteristics that distinguish it mas have a history of vocal abuse or discomfort in the nose. The patient is from others, similar to the character- laryngeal trauma and, on examina- seated and awake during the exami- istics that distinguish a tangerine tion, have signs of reflux laryngitis nation. The flexible laryngoscope al- from an orange, clementine, or grape- and vocal misuse. If the otolaryngolo- lows the physician to see the larynx fruit. However, like the tangerine gist is reasonably certain that the le- in its natural position, without the and clementine, these differences sion is a granuloma, then he or she distortion that sometimes occurs may be subtle. Biopsy may be re- will begin treatment. with holding the tongue forward for quired for definitive diagnosis if any With atypical-appearing lesions mirror and rigid telescopic examina- doubt exists. at the time of the initial examination, tions. In viewing the larynx in its Strobovideolaryngoscopy may a biopsy, which is sampling of the tis- natural position, the physician can be performed, usually with the rigid sue for microscopic examination and assess changes in laryngeal muscle telescope, but it also can be per- diagnosis, is warranted. There are tension while the patient is talking or formed with the flexible laryngo- several other lesions that can mimic singing. From this assessment, the scope. Strobovideolaryngoscopy in- granulomas, and these usually will physician can diagnose abnormal volves the use of synchronized not resolve with the treatments that voice use patterns that may be associ- flashing lights through the telescope are used to treat granulomas. The ated with the development of granu- to evaluate the function of the mu- other possibilities include cancer, be- lomas. Because of the ability to guide cosal wave of the vocal fold. This al- nign tumors (noncancerous abnormal the tip of the laryngoscope into diffi- lows a magnified assessment of the growths), tuberculosis (infection with cult to see positions, flexible laryn- composition of the mass and helps to the tuberculosis bacteria), fun-gal goscopy allows assessment of lesions distinguish solid from fluid-filled le- infections, papillomas (abnormal that are not viewed easily with mirror sions. In addition, a more accurate growths in response to infection by examination and allows a closer view assessment of the effects of the mass the Human Papilloma Virus), and of the mass for better identification. on the ability of the vocal folds to granulomatous diseases (conditions Rigid laryngoscopy presents a close completely or on the mucosal in which the body recognizes itself as more magnified and optically superi- wave to vibrate normally can be per- foreign and has an abnormal reaction or view of the granuloma than the formed. Other changes in the larynx, to itself—not to be confused with mirror or flexible laryngoscopic ex- such as those associated with reflux, granulomas which are inflammatory amination. This procedure is per- can be seen more clearly too. responses to injury).8 formed with a rigid telescope placed through the mouth with the tongue Biopsy held forward. The patient is awake DIAGNOSTIC EVALUATION Biopsies are performed as out- and seated in a forward position dur- patient procedures in the operating Once the examinations are com- ing the examination with the chin room. The patient is given general plete, the otolaryngologist makes a held slightly upright in a "sniffing" anesthesia; that is, the patient is put position. This position helps to pull decision as to whether or not he or

Μαψ/ϑυνε 2002 423 Yolanda D. Heman-Ackah and Robert T. Sataloff to sleep and often intubated, al- system that involves the placement occurs if the patient does not happen though a technique called "jet venti- of a thin, plastic-coated probe to have any reflux episodes during lation" may be used instead of tradi- through the nose and into the esoph- the twenty-four hours that the moni- tional intubation. A laryngoscope agus. The probe has two sensors on it tor is in place, or if the patient's activ- that allows close visualization and that detect the presence of acid. One ities or diet are altered on the day of palpation (touching) of the larynx is probe lies just above the lower the study.11 For singers, it is impor- placed through the mouth. This pro- esophageal sphincter (the region at tant to sing while the pH probe is in cedure is called direct laryngoscopy the junction of the stomach and place, as reflux may occur only dur- and often takes thirty minutes to one esophagus that prevents reflux), and ing singing and may not be detected hour to perform. A microscope is of- the other probe sits near the crico- otherwise. ten used with the laryngoscope to ob- pharyngeus, the upper esophageal The barium swallow study is a tain better definition of the lesion. muscle that sits behind the larynx study in which the patient is given a With the aid of the microscope, the and opens during swallowing to al- barium liquid to drink and X-ray pic- lesion is either excised entirely or a low food to pass into the esophagus. tures and video-recordings are taken portion of the lesion is sampled and The probe is secured to the nose with of the patient as he or she swallows sent to the pathologist. If the lesion is an adhesive and stays in place for the barium liquid. The barium is relatively small, then usually the en- about twenty-four hours. There is a seen readily on the X-ray as it travels tire lesion is excised. If the lesion is small processor that the patient from the mouth into the pharynx, large or if excision of the entire lesion wears on the belt, like a radio, that esophagus, and stomach. If the pa- would result in a significant perma- records the output of each sensor. tient has reflux during the study, it nent functional deficit, such as prob- The patient goes home with the will be seen as regurgitation of the lems with talking, singing, or swal- probe in place and is asked to resume barium from the stomach into the lowing, then a sample of the lesion is normal daily activities. The patient is esophagus. If no reflux is seen, then a obtained. given a diary and is asked to record procedure called barium swallow The pathologist looks at the the activities of the day, such as with water siphonage may be per- biopsy specimen (the sampled lesion) meals, drinking, sensation of reflux formed. In this procedure, water is under the microscope. When the symptoms, exercise, singing, sexual swallowed after the routine barium pathologist makes the diagnosis of activity, and bedtime. Sometimes the study has been completed. X-ray pic- granuloma, he or she has seen signs processor that the patient wears on tures and video-recordings are taken of chronic inflammation without the the belt has buttons that the patient again during these maneuvers. If re- presence of other disease processes. can press to record these events di- flux of the barium is seen after the The presence of lymphocytes (the rectly into the processor. The probe water is drunk, then a diagnosis of blood cells that help with wound is removed after twenty-four hours, reflux is made.11 Because most peo- healing), thickened mucosa, ulcers, and the information is analyzed. The ple who have reflux do not reflux collagen (scar tissue), fibroblasts (the information that can be gained from every time they eat or drink, laryn- cells that make collagen), and an in- the twenty-four-hour pH probe mon- gopharyngeal reflux may not be seen creased number of blood vessels are itor includes the number of episodes on the barium swallow at the time all elements of chronic inflammation of reflux into the pharynx and esoph- that it is performed. For these rea- that help the pathologist make the agus in the twenty-four-hour period, sons, both the barium swallow and diagnosis of granuloma.2,3,9,10 the degree of acidity of the reflux ma- the twenty-four-hour pH probe mon- terial, and the relationship of the re- itoring are perfoiiued as 11 Twenty-Four-Hour pH Probe flux episodes to daily activities. complementary studies in some and Barium Swallow This information can help the oto- patients. The adequacy of reflux control laryngologist tailor the antireflux is evaluated with the aid of a twenty- treatment to the patient's specific Laryngeal Electromyography four-hour pH probe study and a bari- problem areas. Occasionally, the re- Occasionally, the patient has an um swallow study. The twenty-four- sults of the twenty-four-hour pH underlying paresis of the muscles hour pH probe study is a monitoring probe monitor are not helpful. This that move the vocal folds for which he or she tries to compensate by ex-

424 LaryngoSCOPE cessively and abusively using other antecedent history (intubation, up- bed, avoiding eating or drinking for muscles of the larynx. Such hyper- per respiratory tract infection, vocal at least three hours before bedtime, function may cause or aggravate abuse, etc.). If the appearance and lo- avoiding exercising any sooner than granulomas. This can sometimes be cation of the lesion is very typical for two hours after eating, increasing ex- seen with flexible laryngoscopy and a granuloma, the patient is treated ercise activity, losing weight, avoid- strobovideolaryngoscopy during vo- for laryngopharyngeal reflux and is ing excessive amounts of beverages cal exercises that require the vocal given a course of voice therapy. and foods that contain caffeine, folds to abduct (open) and adduct avoiding excessive amounts of foods (close) rapidly. Sometimes, these ab- Management of Reflux and beverages high in citric acid con- normalities can be missed on exami- The treatment of reflux consists tent, avoiding excessive amounts of nation. When paresis is seen on ex- of both medications and behavioral dairy products, and stopping smok- amination or when a neurologic modifications in the patient's ing and/or the use of other tobacco problem is suspected, a laryngeal lifestyle. The medications commonly products. Nicotine (which is present electromyography (LEMG) is ob- used to treat laryngopharyngeal re- in tobacco products) and caffeine tained. This is a diagnostic test in cause relaxation of the lower flux are proton-pump inhibitors, H2- which small needles are placed in the receptor blockers, and antacids. esophageal sphincter (the muscle muscles of the larynx. The nerves of that pre-vents reflux), thus rendering These medications function by de- 14 the larynx produce an electric cur- creasing the amount of acid in the it unable to perform its function. rent whenever they signal the mus- stomach; they do not prevent reflux The avoidance of caffeine and cles of the larynx to move. The nee- episodes from occurring. By decreas- tobacco can have a substantial dles that are placed into the muscles ing the amount of stomach acid, they positive effect on this muscle's sense the electricity that the nerves decrease the amount of acid expo- ability to maintain its tone and produce and transmit the signal to a sure the larynx experiences from the prevent reflux episodes. Dairy monitor. A healthy and strong nerve reflux episodes. Greater amounts of products and foods and beverages produces a different signal than does acid on the larynx cause a greater de- high in citric acid increase the acid a paretic (weak) nerve or a paralyzed content of the stomach, thus in- 12 13 gree of injury and inflammation. (nonfunctioning) nerve. , If pare- Gastric motility agents are used occa- creasing the acidity of the reflux ma- sis of a specific nerve or muscle sionally in the treatment of reflux as terial that reaches the larynx. Eating group is noted on LEMG, therapeutic well. These agents work by increas- and drinking stimulate the stomach approaches that are aimed at aug- ing the motility of the gastrointesti- to produce acid and stimulate the menting vocal fold function can be nal system, which limits the amount stomach to churn as a part of the di- taken. of time that gastric contents stay in gestive process. If this occurs within the stomach, thus limiting the num- three hours of lying down to sleep, ber of reflux episodes. Gastric the churning of the stomach can TREATMENT force the excess acid produced for di- motility agents are used seldom because they have many side effects. gestion into the esophagus and up to Once the physician sees a lesion the larynx. that he or she suspects is a granulo- The only way to prevent reflux from occur-ring is to have surgery to Elevation of the head of the bed ma, there are several courses of ac- by at least six inches relative to the tion the physician may take. The one tighten the muscle that prevents the stomach contents from regurgitating foot of the bed helps to keep the lar- chosen depends on the physician's ynx higher than the level of the stom- certainty that the lesion is indeed a into the esophagus. Few people need the surgery to control the reflux ade- ach while sleeping, and the force of granuloma, on the presence of other gravity helps to keep the stomach signs and/or symptoms of laryn- quately. Most people do well with the medications and with behavioral contents in the stomach. The use of gopharyngeal reflux, on the presence 3 more than two pillows is discouraged of abnormal muscle tension with modifications. a Behavioral modifications to help because this form of head elevation singing or talking as seen on flexible often results in a bending of the body laryngoscopy, and on details of the control laryngopharyngeal re-flux include: elevating the head of the at the waist, which results in pres- sure on the stomach. This pressure

Μαψ/ϑυνε 2002 425 Yolanda D. Heman-Ackah and Robert T. Sataloff

squeezes the stomach and may in- ing both speaking and singing. that uses light energy to vaporize and crease the number and duration of Speech and voice therapy occur over cut tissue. Because the laser uses reflux episodes. Exercising too soon the course of several sessions to en- light energy, heat is released by the 15 16 after eating has a similar effect on sure that the patient is practicing cor- laser as it cuts. , On the one hand, abdominal pressure and increases rect technique at home and work and the laser is advantageous in the exci- re-flux. Singing, which requires a to help reinforce healthy vocal pat- sion of granulomas because they tend significant amount of abdominal terns. For many patients, control of to bleed as they are cut, and the laser support, is a form of exercise. Excess the reflux and speech and voice ther- is able to cause clotting of blood as apy result in resolution of granulo- the heat energy is released. On the weight in the abdominal region also mas. This may take several months other hand, some surgeons believe exerts a pressure effect on the to completely resolve, but improve- that because the heat released from stomach, especially while lying ment should be noted after six weeks the laser results in a minor burn in- down. Weight loss of as little as five 5 8 of adequate therapy. ' jury itself, the laser may actually pre- to ten pounds can have a beneficial dispose to further granuloma and scar effect, decreasing the number of 5,16 Management of Recurrent and formation.' The presence of scar reflux episodes. Persistent Granulomas on the vocal fold or vocal process can

In approximately fifteen to interfere with the normal vibratory Voice Rehabilitation twenty percent of the patients with function of the vocal fold mucosa, Speech and voice therapy are granulomas, the lesion continues to thus producing a hoarse voice. For beneficial and probably are the most grow or cause symptoms after six to these reasons, some surgeons prefer important components of the treat- eight weeks of adequate voice thera- to use the scalpel or scissors. Topical ment of granulomas. Speech and py and reflux control. In these in- vasoconstrictors, which are voice therapists evaluate the patient's stances, excision of the lesion with medications that are applied directly current vocal patterns and behaviors either steroid injection directly into to bleeding vessels to cause them to and help the patient to modify those the granuloma or systemic adminis- constrict and stop bleeding, are used behaviors that may be damaging to tration of steroids via pills or shots is with the cold technique as needed. the larynx. Most often, patients with performed. Excision is performed in Once the granuloma is excised, laryngeal granulomas show signs of the operating room as an outpatient the surgeon may inject steroids di- muscle tension dysphonia. As de- procedure in a manner similar to the rectly into the tissue where the gran- scribed earlier, muscle tension dys- procedure described for biopsy. This ulomas were found. The steroids phonia is the abnormal or excessive time, the entire lesion is removed and used are variations of substances use of the accessory muscles of sent to the pathologist to confiim the found naturally in the body that de- phonation. These include muscles diagnosis of granuloma. Sometimes, crease inflammation; these are differ- that control the false vocal folds very small abnormal growths, such ent from the anabolic steroids some- (which are the folds of tissue above as the ones previously mentioned, times used by athletes to enhance the vocal folds), the pharyngeal can be associated with surrounding performance and do not have the (throat) muscles, the tongue, the neck inflammation that looks like a granu- same masculinizing effects on the muscles, the jaw muscles, the mouth loma and that may have been missed voice and body that anabolic steroids muscles, the palatal (roof of the on the first biopsy. Excision of the have. Injection of steroids into the mouth) muscles, the shoulder entire lesion should give a definitive tissue where the granulomas were muscles, the abdominal muscles, the diagnosis. formed may help to prevent further back muscles, and the chest muscles. Sometimes the granulomas are inflammation and granuloma forma- Inappropriate use of any of these excised with a scalpel or scissors, a tion. Sometimes, steroids are given muscles can place a significant strain technique often referred to as the systemically (taken by mouth or giv- on the laryngeal muscles, resulting in "cold technique," and sometimes en as a shot) over the course of up to vocal fold trauma. they are excised with the laser, which several weeks to help prevent forma- The goals of speech and voice is often referred to as the "hot tech- tion of the granulomas. The advan- therapy are to relearn how to relax nique." The laser is merely a knife tage of using systemic steroids over the muscles of phonation and how to achieve optimal breath support dur-

426 ϑουρναλ οφ Σινγιν γ „ LaryngoSCOPE

direct injections of steroids is that the linum toxin is a substance produced sions that do not respond to treat- systemic form of the steroid can be by the bacteria that cause botulism. ment. Patients with recalcitrant, given over longer periods of time, Botulinum toxin works by causing a symptomatic lesions may require yielding a longer anti-inflammatory paresis of the muscles to which it is more aggressive treatment, including effect. Excision is always followed by exposed. In patients with granulo- the use of steroids, repeated excision a reevaluation by the speech and/or mas, it is thought that the lateral of granulomas, abdominal surgery voice therapists to ensure that proper cricoarytenoid muscle of the larynx for reflux, and botulinum toxin injec- vocal technique is being used to min- is hyperactive, causing forceful clo- tions into the laryngeal muscles. imize trauma in the surgical area. sure of the vocal folds at the level of Reevaluation of the adequacy of the vocal process, the site most often 8 voice rehabilitation involves assess- involved with granulomas. Weaken- NOTES ment of the patient's compliance with ing of this muscle with the botu- the recommendations of speech/ linum toxin injection prevents this 1. R. T. Sataloff, "Common Medical voice therapy. Sometimes, unknow- forceful closure and limits the Diagnoses and Treatments in Profes- ingly, the patient incorrectly prac- amount of trauma that can be caused sional Voice Users," in R. T. Sataloff, tices at home the vocal exercises that to the vocal process. Speech and ed., Vocal Health and Pedagogy (San he or she has been given. This can re- voice therapy are continued after bot- Diego, CA: Singular Publishing sult in more injury to the larynx and ulinum toxin injections; without the Group, 1997), 108. should be identified and corrected. forceful contractions of the lateral The use of speech and voice cricoarytenoid muscle, sometimes it 2. W. Lehmann and J. J. Widman, "Nonspecific Granulomas of the Lar- therapy, antireflux medications, anti- is easier for the patient to learn ynx," in J. A. Kirchner, ed., Vocal reflux behavior modification, exci- healthy vocal technique. Fold Histopathology: A Symposium sion, and steroid therapy when nec- (San Diego, CA: College-Hill Press, essary is successful in resolving the 1986), 97-107. granulomas in most patients. There SUMMARY are some patients in whom, despite 3. W. J. Gould, J. S. Rubin, and E. adequate treatment, the granulomas Granulomas are inflammatory Yanagisawa, "Benign Vocal Fold still recur. This occurs in approxi- lesions that can occur anywhere in Pathology Through the Eyes of the mately five percent of the patients the larynx, but typically occur in the Laryngologist," in J. S. Rubin, R. T. with granulomas. Sometimes this is posterior regions of the vocal folds on Sataloff, G. S. Korovin, and W. J. Gould, eds., Diagnosis and Treatment directly related to vocal misuse that is the vocal process of the arytenoid cartilage. Granulomas are caused by of Voice Disorders (New York: Igaku- not adequately corrected with con- Shoin; 1995), 146-148. ventional speech and voice therapy. trauma, which can take the form of In other patients, there is no identifi- vocal abuse, vocal misuse, laryn- 4. R. T. Sataloff, D. O. Castell, P. O. able cause for the recurrence. If the le- gopharyngeal reflux, intubation, or Katz, and D. M. Sataloff, "Gastro- sions are not symptomatic, no further surgical or other trauma. The main- esophageal Reflux Disease: An treatment is needed and the lesions stay of treatment of granulomas in- Overview of Clinical Presentation and are monitored closely with serial ex- volves identification and removal of Epidemiology," in R. T. Sataloff, D. aminations. Lesions that continue to the inciting irritant, speech and voice O. Castell, P. O. Katz, and D. M. be symptomatic may require repeat- rehabilitation, and treatment of Sataloff, eds., Reflux Laryngitis and Related Disorders (San Diego, CA: ed excision and steroid injection or laryngopharyngeal reflux. The re- sults of barium swallow studies, Singular Publishing Group, 1999), 33- ingestion. Some otolaryngologists 40. have used botulinum toxin (Botox) twenty-four-hour pH probe monitor- ing, and laryngeal electromyography injections into the muscles that most 5. D. G. Hanson, P. L. Kamel, and P. J. likely are responsible for the exces- may guide therapy. Excisional biopsy Kahrilas, "Outcomes of Antireflux sive trauma to the portion of the vo- is considered for patients with atypi- Therapy for Treatment of Chronic cal fold with the granuloma.8 Botu- cal lesions and for patients with le Laryngitis," Annals of Otolology Rhi- nology and Laryngology 104 (1995): 550-555.

Μαψ/ϑυνε 2002 427 Yolanda D. Heman-Ackah and Robert T. Sataloff

6. R. T. Sataloff, J. R. Spiegel, and D. "Laryngeal EMG: Electromyograph- Neck Surgery, Thomas Jefferson University; C. Rosen, "The Effects of Age on ic Evaluation of Vocal Fold Disor- Chairman, Department of Otolaryngolo- the Voice," in R. T. Sataloff, ed., ders," Journal of Singing 55, no. 2 gy—Head and Neck Surgery, Graduate Vocal Health and Pedagogy (San (Nov/Dec 1998):43-48. Diego, CA: Singular Publishing Hospital; Adjunct Professor, Department of Group, 1997), 123-131. 13. J. A. Koufman and F. O. Walker, Otorhinolaryngology, University of Penn- "Laryngeal Electromyography in sylvania; Adjunct Professor, Department 7. W. J. Gould and J. S. Rubin, "Spe- Clinical Practice: Indications, Tech- of Otolaryngology—Head and Neck cial Considerations for the Profes- niques, and Interpretation," Phono- Surgery, Georgetown University School of sional Voice User," in J. S. Rubin, R. scope 1(1998):57-70. Medicine; and Chairman, The Voice T. Sataloff, G. S. Korovin, and W. J. Foundation; and Chairman, The Ameri- Gould, eds., Diagnosis and Treatment 14. R. T. Sataloff, D. O. Castell, P. O. can Institute for Voice and Ear Research. of Voice Disorders (New York: Katz, and D. M. Sataloff, "Behav- Igaku-Shoin; 1995), 424-435. ioral and Medical Management of He has authored more than 500 publica- Gastroesophageal Reflux Disease," tions, including twenty books. 8. R. T. Sataloff, D. O. Castell, P. O. in R. T. Sataloff, D. O. Castell, P. O. Katz, and D. M. Sataloff, "Reflux Katz, and D. M. Sataloff, eds., Re- Laryngitis and Other Otolaryngo- flux Laryngitis and Related Disor- logic Manifestations of Laryngopha- ders (San Diego, CA: Singular Pub- ryngeal Reflux," in R. T. Sataloff, lishing Group, 1999), 69-87. D. O. Castell, P. O. Katz, and D. M. Sataloff, eds., Reflux Laryngitis and 15. J. Werkhaven and R. H. Ossoff, Related Disorders (San Diego, CA: "Surgery for Benign lesions of the REPRODUCED WITH Singular Publishing Group, 1999), Glottis," Otolaryngology Clinics of PERMISSION FROM THE 41-53. North America 24 (1991):1179-1199. NATIONAL ASSOCIATION OF 9. I. Mossallam et all., "Histopathologi- 16. M. S. Courey and R. H. Ossoff, TEACHERS OF SINGING cal Aspects of Benign Vocal Fold "Surgical Management of Benign Lesions Associated with Dyspho- Voice Disorders," in J. S. Rubin, R. nia," in J. A. Kirchner, ed., Vocal T. Sataloff, G. S. Korovin, W J. Fold Histopathology: A Symposium Gould, eds., Diagnosis and Treat- (San Diego, CA: College-Hill Press, ment of Voice Disorders (New York: 1986), 65-80. Igaku-Shoin, 1995), 366-382.

Yolanda D. Heman-Ackah, MD., is Assis- 10. O. Kleinsasser, Microlaryngoscopic tant Professor of Laryngology and Profes- and Histologic Appearances of Polyps, Nodules, Cysts, Reinke's sional Voice Care in the Department of Edema, and Granulomas of the Otolaryngology—Head and Neck Surgery Vocal Cords," in J. A. Kirchner, ed., at the University of Illinois at Chicago. She Vocal Fold Histopathology: A is the director and founder of the Voice Symposium (San Diego, CA: Center at the University of Illinois at College-Hill Press, 1986), 51-55. Chicago. She has authored and coauthored

numerous publications in the fields of 11. R. T. Sataloff, D. O. Castell, P. O. Katz, and D. M. Sataloff, "Diagnos laryngology and professional voice care, tic Tests for Gastroesophageal including award-winning scientific jour- Reflux," in R. T. Sataloff, D. O. nal articles, book chapters, and a book. Castell, P. O. Katz, and D. M. Sat aloff, eds., Reflux Laryngitis and Related Disorders (San Diego, CA: Singular Publishing Group, 1999), 55-68.

12. S. Mandel, R. Manon-Espaillat, S. Robert Thayer Sataloff, MD., D.M.A., is D. Patterson, and R. T. Sataloff, Professor of Otolaryngology—Head and 428