Contact granuloma is a condition that develops due to persistent tissue irritation in the posterior
larynx
The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...
.
Benign granulomas, not to be confused with other types of
granuloma
A granuloma is an aggregation of macrophages that forms in response to chronic inflammation. This occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate. Such substances include infectious ...
s, occur on the vocal process of the
vocal folds
In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speech ...
, where the vocal ligament attaches. Signs and symptoms may include hoarseness of the voice, or a sensation of having a lump in the throat, but contact granulomas may also be without symptoms.
There are two common causes associated with contact granulomas; the first common cause is sustained periods of increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively, such as singers (
John Mayer
John Clayton Mayer ( ; born October 16, 1977) is an American singer, songwriter, and guitarist. Born and raised in Fairfield County, Connecticut, Mayer attended Berklee College of Music in Boston, but left and moved to Atlanta in 1997 with ...
, for example). Treatment typically includes voice therapy and changes to lifestyle factors. The second common cause of granulomas is
gastroesophageal reflux
Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
and is controlled primarily through the use of anti-reflux medication.
Other associated causes are discussed below.
Signs and symptoms
The primary symptoms of contact granuloma include
chronic or
acute
Acute may refer to:
Science and technology
* Acute angle
** Acute triangle
** Acute, a leaf shape in the glossary of leaf morphology
* Acute (medicine), a disease that it is of short duration and of recent onset.
** Acute toxicity, the adverse eff ...
hoarseness
A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice, can be associated with a feeling of unease or scratchiness in the ...
of the voice and vocal fatigue.
More severe granulomas may result in throat ache or soreness, as well as pain that spreads to one or both ears.
Smaller granulomas may result in a tickling sensation or slight discomfort.
Signs of contact granulomas are frequent coughing and throat-clearing.
Some people may also notice that their pitch range is restricted due to granuloma.
Causes
The major etiologic factors of contact granulomas have been organized into the following categories:
Mechanical issues
Mechanical issues resulting in contact granulomas are related to physical trauma at the level of the vocal folds.
Trauma occurs when adductive forces are excessive, meaning that a person's vocal folds are closing abruptly and forcefully while speaking or engaging in other non-vocal behaviors (such as throat-clearing and coughing).
In addition, the presence of the contact granuloma makes it impossible for the vocal folds to come to a complete closure in adduction. This causes the person to use more force when speaking in an attempt to close the vocal folds completely, which in turn creates more trauma to the vocal folds.
Glottal insufficiency (when the vocal folds cannot close completely, often due to vocal fold
paralysis
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
) can also be an underlying cause of contact granulomas.
Contact trauma can occur when a person frequently speaks at a pitch that is lower than their
modal voice
Modal voice is the vocal register used most frequently in speech and singing in most languages. It is also the term used in linguistics for the most common phonation of vowels. The term "modal" refers to the resonant mode of vocal folds; that is ...
, especially in vocally-demanding professions like acting, teaching and singing.
Research suggests that men are more commonly affected than women.
Inflammatory issues
Inflammatory issues associated with contact granuloma include
gastroesophageal reflux
Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
, allergy or infection.
There is some disagreement among researchers as to whether inflammatory issues are a direct cause.
Some researchers identify reflux and infection as indirect causes due to aggressive coughing that usually occurs as a result.
Intubation
For patients in need of
tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer ce ...
to receive oral drugs, an oversized tube, excessive movement of the tube, or infection can lead to contact granulomas, but this is rare.
Psychosocial factors
People with certain personality traits and vocal patterns may be more susceptible to the development of contact granulomas.
Tenseness, high-stress, aggressiveness and impulsiveness are personality traits associated with contact granuloma.
Diagnosis
Diagnosis of contact ulcers normally involves an
endoscopy
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
examination, and a
biopsy
A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
sample is taken so that the ulcer can be examined for
cancerous cells.
Physical characteristics
Contact granulomas can be physically identified and diagnosed by observing the presence of
proliferative tissue originating from the
vocal process
In the human larynx, the vocal process is the anterior angle of the base of the arytenoid cartilage, as it projects horizontally forward and gives attachment to the vocal ligament.
The arytenoids are paired cartilages with a medial and a lateral ...
of the
arytenoid cartilage
The arytenoid cartilages () are a pair of small three-sided pyramids which form part of the larynx. They are the site of attachment of the vocal cords. Each is pyramidal or ladle-shaped and has three surfaces, a base, and an apex. The arytenoid ...
.
Identification is carried out by laryngoscopy, which produces an image of the lesion in the form of an abnormal growth (
nodule or
polyp) or
ulceration
An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...
.
The vocal process is overwhelmingly the most common laryngeal site for these lesions, although they have also been observed on the medial and anterior portions of the vocal folds.
In nodule or polyp form, contact granulomas generally have a grey or dark red colouring
and measure 2 to 15 mm in size.
Contact granulomas can occur unilaterally or bilaterally, affecting one or both vocal folds.
Differential diagnosis
Various methods are used to diagnose contact granuloma which aid in differentiating it from other
vocal fold
The human voice consists of sound made by a human being
Humans (''Homo sapiens'') are the most abundant and widespread species of primate, characterized by bipedality, bipedalism and exceptional cognitive skills due to a large and compl ...
pathology.
Laryngoscopy
Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...
can allow visualization of the suspected granuloma while also checking for signs of vocal abuse.
Laryngoscopy, as well as an
acoustic analysis of the voice, can help rule out vocal fold
paresis
In medicine, paresis () is a condition typified by a weakness of voluntary movement, or by partial loss of voluntary movement or by impaired movement. When used without qualifiers, it usually refers to the limbs, but it can also be used to desc ...
as an underlying cause.
Microscopic examination of the
tissue can help determine that the
lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
is benign rather than
cancer
Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...
ous, as would be the case in contact granuloma.
Other methods such as laryngeal electromyography and reflux testing can also be used to evaluate the function of the vocal folds and determine if
laryngopharyngeal reflux
Laryngopharyngeal reflux (LPR) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as ...
is contributing to the pathology.
Screening
Screening tools for contact granulomas are not currently available. Diagnosis of contact granulomas require visualization using
laryngoscopy
Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...
, and may require further biopsy for
differential diagnosis
In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...
.
A combination of symptoms and lifestyle factors may be linked with the development of a contact granuloma, however symptoms vary greatly by individual. Some lifestyle factors that have been linked with elevated risk of development of contact granulomas include frequent use of the voice, especially when in loud environments, and concurrent use of the voice with alcohol consumption (increasing risk of
gastroesophageal reflux
Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
symptoms). Contact granuloma may also arise after intubation, and so following intubation, patients should be monitored if voice symptoms arise. Symptoms may or may not include
hoarse voice
A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice, can be associated with a feeling of unease or scratchiness in the ...
, described as "huskiness" by some patients,
"aching" in the throat related to increased effort to produce voice,
and the feeling of having a lump in one's throat when swallowing.
It is also possible to have no such symptoms, especially if the granuloma is small.
A patient presenting with such symptoms or risk factors should therefore be referred for further visualization. It is therefore recommended to obtain a diagnosis from a doctor.
Prevention
The causes of vocal process granulomas are quite varied, and as such prevention must target the individual causes.
Education on lifestyle factors such as habitual vocal abuse and habits that may aggravate gastro-esophageal reflux should be implemented to lower risk, and those who use their voice professionally should use vocal hygiene techniques to ensure safe voice use.
Vocal hygiene may include increasing water intake, eliminating external irritants such as smoking or airborne chemicals, controlling loudness, and balancing periods of increased vocal use with periods of rest. Since intubation can also cause vocal process granulomas, proper muscle relaxing medications should be used before insertion and removal of tubes, that smaller tubes are used and with proper lubrication, and that patient movement is controlled during intubation.
Treatment
Specific treatment for contact granuloma depends on the underlying cause of the condition, but often initially includes a combination of
speech therapy
Speech is a human vocal communication using language. Each language uses phonetic combinations of vowel and consonant sounds that form the sound of its words (that is, all English words sound different from all French words, even if they are th ...
,
vocal rest
Vocal rest or voice rest is the process of resting the vocal folds by not speaking and singing typically following viral infections that cause hoarseness in the voice, such as the common cold or influenza or more serious vocal disorders such as c ...
,
and antireflux medication.
A more aggressive treatment approach could include
steroid
A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
s (inhalant or injection),
injections of
botulinum toxin
Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromusc ...
,
low dose
radiotherapy
Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...
, vocal fold augmentation,
or microlaryngeal surgery).
Microlaryngeal surgery can be performed either via cold steel
excision or various types of laser.
The laser is more accurate and typically results in less damage to the surrounding tissue. These more aggressive approaches might be used in the case of the refractory (i.e. resistant to treatment) contact granuloma where previous interventions have not succeeded or recurrence rates are high.
The best outcomes appear to occur when a combination of treatments is used.
Steroids
The application of corticosteroids to treat contact granulomas is considered a more extreme approach
and its utility remains in contention.
When employed, it is usually used in conjunction with antibiotics for the reduction of pain and inflammation related to the granuloma.
This treatment can be administered orally, through inhalation, or through intra
lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
injection.
Botox injection
The injection of botulinum neurotoxin A, or Botox, to treat contact granulomas is considered a more extreme approach,
and is generally only pursued when the case has been resistant to other treatments.
In this approach, Botox is injected into the
thyroarytenoid muscle (unilaterally or bilaterally), targeting a reduction in the
contact force
A contact force is any force that occurs as a result of two objects making contact with each other. Contact forces are ubiquitous and are responsible for most visible interactions between macroscopic collections of matter. Pushing a car or kickin ...
s of the arytenoids.
Surgery
When all other medical and behavioural treatments have been attempted, surgical removal of the contact granuloma is possible as a last resort option. However, caution needs to be exercised, especially in the cases of contact granuloma resulting from external factors (i.e., when factors are eliminated, the contact granuloma resolves independently), because any irritation can cause the contact granulomas to reappear.
Prognosis
As the masses of granular tissue are most often
benign
Malignancy () is the tendency of a medical condition to become progressively worse.
Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous benign tumor, ''benign'' tumor in that a malign ...
, prognosis is generally positive.
However, due to the variety of treatment options and lifestyle factors, outcomes of individual treatments and form of management vary. A high proportion of contact granulomas are present in patients with concurrent
gastroesophageal reflux
Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
, and so treatment of the reflux is imperative.
Those caused by intubation trauma are less likely to recur.
The most common treatment is voice therapy by a speech-language pathologist, and this therapy is enough for many patients.
Surgical solutions are sometimes used, however rates of recurrence are higher.
Most recent research suggests that surgical options should only be explored once treatment of reflux with or without voice therapy has been introduced.
Epidemiology
Across all posited etiologies, contact granulomas are more commonly observed in male patients than in female patients, and more commonly in adult patients than in pediatric patients.
In cases where gastroesophageal reflux disease is identified as the most likely cause of the granuloma, the patient is most commonly an adult man in his 30s or 40s.
When contact granulomas do occur in female and pediatric patients, they usually occur post-intubation.
There are no observable age or gender trends within the category of post-intubation patients with contact granulomas, nor within the causation category of vocal abuse history.
Terminology
Several different terms are used to refer to contact granulomas (contact ulcer, vocal fold granuloma, vocal process granuloma, etc.). The term ''contact ulcer'' was first used in the early 20th century at which time the single cause of this condition was believed to be excessive force when the vocal folds make contact during phonation or non-phonatory behaviors (i.e. coughing).
Later, the same condition was observed in patients recovering from recent intubation
and, more recently, came to be associated with inflammation and irritation resulting from gastro-esophageal reflux.
Likewise, use of both ''ulcer'' and ''granuloma'' reflect the fact that this condition can present as an ulcerated lesion or as granulated tissue.
In medical literature today, the term ''vocal process granuloma'' is preferred over the term ''contact ulcer'' or ''contact granuloma;'' this reflects the fact that this condition can result from a variety of different causes and not just excessively forceful contact of the vocal folds as was originally believed.
Nevertheless, the term ''contact granuloma'' remains widely used.
Sources
Excerpt from Contact Granulomas - eMedicine
References
{{Reflist
Larynx disorders