Contact Granulomas
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Contact granulomas are benign lesions usually located on the posterior third of the vocal fold, which corresponds to the vocal process of the arytenoid cartilage. Contact granulomas may occur unilaterally or bilaterally.
Granulomas of the larynx can be classified into 2 general groups: specific granulomas and nonspecific granulomas. Specific granulomas are rare and include granulomas caused by tuberculosis [1] and syphilis. Nonspecific granulomas are benign and are unilaterally or bilaterally located on the vocal processes of the vocal folds. Histologically, they resemble pyogenic granulomas.
See the image below.
Contact ulcers (or granulomas) historically were thought to be the result of voice abuse or misuse, and the granulomas of intubation or gastroesophageal reflux were separate subsets of these conditions. However, for all purposes, the appearance, symptomatology, and treatment of these nonspecific granulomas are identical; therefore, both subsets of nonspecific granulomas can be considered a single entity.
Chevalier Jackson first identified contact ulcers in 1928. [2] He collected 127 case reports dating to 1888. In 1935, Jackson and Jackson suggested a mechanical cause related to the hammer and anvil effect of the vocal processes colliding against each other, leading to superficial mucosal ulceration (the contact ulcer) and focal granulation tissue response. [3]
A contact granuloma is a pale or sometimes red mass located on the medial aspect of the vocal process of the arytenoid cartilage. Histologically, contact granulomas resemble pyogenic granulomas, which consist of chronic inflammatory infiltration with neovascularization and fibrosis covered by squamous epithelium.
Classic contact ulcers are thought to be the result of vocal misuse and abuse. With this etiology, the lesion most commonly is identified in men. These lesions often are similar in appearance to those found in patients after intubation (intubation granulomas) and in patients with gastroesophageal reflux.
Occasionally, a vocal process granuloma is identified in a patient for whom none of these factors are apparent. de Lima Pontes et al label this group idiopathic. The literature contains much confusion about this entity; however, for practical purposes, these lesions may be conceptualized as a group.
Primary causes of contact granulomas may coexist in the same patient and include the following:
Intubation (see video below)
Voice abuse
Laryngopharyngeal reflux disease
Idiopathic
Factors that contribute to the development of contact granulomas include smoking, allergy, infections, postnasal drip, and chronic throat clearing. Psychosocial traits associated with development of contact granulomas include aggressive personality, introversion, depression, emotional tension, and/or cancerophobia.
Certain dietary factors may affect the laryngeal milieu, leading to a detrimental mucosal environment. These factors include consumption of caffeine, chocolate, alcohol, peppermint, spicy foods, and tomato products; high-fat diet; poor water intake; and use of tobacco products. However, a direct causal relationship in the formation of contact ulcers has not been established.
Differential diagnoses include carcinoma, granular cell tumor of the larynx, and sarcoid.
Contact granulomas are usually pale, pedunculated masses found on the medial or superior edge of the vocal process of the arytenoid cartilage; however, they may also be deep red, lobulated, and sessile. These lesions may be 2-lipped structures that fit the vocal process of the opposite side.
Contact ulcers occur when the thin mucosa overlying the firm cartilage of the vocal process is crushed repetitively against the opposite side, causing a breakdown of the mucosa. An ulcer forms, accompanied by granulation tissue formation. An object such as an endotracheal tube may cause the injury leading to granulomas, or granulomas may result secondary to chronic irritation (eg, persistent gastroesophageal reflux injury).
A study by Li et al suggested that a finding of arytenoid cartilage sclerosis signals the presence of contact granuloma. High-resolution computed tomography (CT) scanning revealed that in patients with contact granuloma (41 with unilateral lesions and one with bilateral lesions), arytenoid cartilage sclerosis existed on 79.07% of the vocal folds with lesions, compared with 7.32% of those without lesions. The rate of arytenoid sclerosis associated with contact granuloma was also significantly greater than that for the lesion or nonlesion sides of vocal folds (13.11% or 2.56%, respectively) in patients with glottic laryngeal cancer or vocal cord leukoplakia without vocal process involvement. [4]
Symptoms include the following:
Varying degrees of hoarseness and a low-pitched, pressed voice quality
Cough
Throat clearing
Pain, especially on pressed phonation or with cough or throat clearing
A rough foreign body sensation
The physician inquiry includes the following:
Intubation history, including nasogastric intubation
Reflux and associated high-risk habits (eg, dietary habits, caffeine intake)
Vocal use patterns (eg, glottal fry, hard glottal attack)
Pulmonary characteristics (eg, chronic cough, use of inhalers)
Even in relatively asymptomatic disease, treat the contact ulcer or vocal process granuloma to prevent growth and possible complications or sequelae of the inflammatory process, which include the following:
Airway obstruction
Bleeding (usually minor)
Vocal fold fixation
Posterior laryngeal stenosis
Surgical management of these lesions usually is frustrating because of a 37-50% recurrence rate. Surgical interventions are indicated for the following:
Fibroepithelial polyp
Airway compromise
Suspicion of carcinoma
Apices of the arytenoid cartilages are composed of elastic cartilage, and the rest of the arytenoid cartilage is hyaline cartilage. The arytenoid cartilages begin to ossify at approximately age 30 years. Ulcer or granuloma occurs on the vocal process of the arytenoid cartilage. The vocal process accounts for the posterior third of the vocal cord where the vocal ligament attaches.
The mucosa covering the vocal processes of the arytenoid cartilage is a thin layer of stratified squamous epithelium. This thin layer of mucosa is susceptible to being crushed between any unyielding object (eg, an endotracheal tube, the opposite arytenoid) and the firm cartilage beneath the mucosa.
Surgery is discouraged as the initial management for 2 reasons. Surgery is associated with a high recurrence rate of 37-50%, which often leads to multiple surgeries that may still be unsuccessful. Surgery may also cause the granuloma to migrate, following the wound edge.
Beham AW, Puellmann K, Laird R, Fuchs T, Streich R, Breysach C, et al. A TNF-regulated recombinatorial macrophage immune receptor implicated in granuloma formation in tuberculosis. PLoS Pathog. 2011 Nov. 7(11):e1002375. [Medline]. [Full Text].
Jackson C. Contact ulcer of the larynx. Ann Otol Rhinol Laryngol. 1928. 37:227-30.
Jackson C, Jackson CL. Contact ulcer of the larynx. Arch Otolaryngol. 1935. 22:1-15.
Li J, Tian S, Zou S, Wang Q, Tai X, Chen X. CT Study of the Arytenoid Cartilage in Patients with Laryngeal Contact Granuloma. Otolaryngol Head Neck Surg. 2017 Dec. 157 (6):1013-6. [Medline].
Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. 2009 Aug. 13(8):1422-9. [Medline].
Yılmaz T, Kayahan B, Gunaydın RO, Kuscu O, Sozen T. Botulinum Toxin A for Treatment of Contact Granuloma. J Voice. 2016 Nov. 30 (6):741-3. [Medline].
Lee SW, Hong HJ, Choi SH, et al. Comparison of treatment modalities for contact granuloma: a nationwide multicenter study. Laryngoscope. 2014 May. 124 (5):1187-91. [Medline].
Jin YJ, Lee SJ, Lee WY, Jeong WJ, Ahn SH. Prognostic factors for prediction of follow-up outcome of contact granuloma. Eur Arch Otorhinolaryngol. 2014 Jul. 271 (7):1981-5. [Medline].
James D Garnett, MD Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
James D Garnett, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
John Schweinfurth, MD Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association
Disclosure: Nothing to disclose.
Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.
Contact Granulomas
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