Diagnosis of Vocal Fold Granuloma

Key Glossary Terms

Vocal Fold Granuloma
Pale, sometimes red, mass on vocal folds resulting from irritation; contains inflammatory cells, new blood vessels; usually found over arytenoid cartilages at the site of contact during vocal fold closure

Vocal Folds
Also known as vocal cords; a pair of muscular ligaments in the voice box (larynx) which vibrate to produce sound

Arytenoid Cartilages
Pair of pyramid-shaped cartilages to which the vocal folds are attached in the back of the voice box; spaced well apart for normal breathing; come together for sound production

Glossary

As with other voice disorders, a stepwise process is necessary to identify vocal fold granulomas and the cause or causes of vocal fold granuloma formation. Identification of the cause or causes is especially important since treatment and long-term control of vocal fold granulomas relies on treatment of the cause or causes.

Information regarding events in a patient's life that might contribute to granuloma formation can provide clues in the identification of vocal fold granulomas, such as: possible voice misuse, laryngopharyngeal reflux, and use of breathing tube.

Although the presence of any of these risk factors cannot conclusively determine the presence of granuloma, they suggest you may have developed vocal fold granuloma or are at risk of developing vocal fold granuloma.

A Note on Physical Exam

A general physical exam is also performed to evaluate for possible other findings, which could be helpful in the evaluation of any and all voice disorders.

Examination of the voice box area can be done by:

A small mirror is placed at the back of the mouth and reflects light down towards the throat and larynx. With proper lighting, an image of the throat and voice box can be observed on the mirror – much like a rearview mirror in a car. Vocal fold granuloma can be visualized on a properly performed mirror examination.

Flexible (or rigid) fiberoptic laryngoscopy is performed using a specialized instrument that is basically a thin tube with a light source and magnifying viewing system. The tube, called a fiberoptic laryngoscope, can be placed through either the nose or mouth and positioned down the throat to directly view the voice box from above. The fiberoptic laryngoscope allows an "up-close" look at the vocal folds and usually provides a sufficiently clear picture to allow for the identification of granuloma. (For more information, see Laryngoscopy/Stroboscopy.)

Key Information

Critical View of the Back of the Voice Box

Since granulomas typically develop in the posterior (back) of the vocal folds over the arytenoid cartilages, that portion of the voice box must be visualized well.

"Sniffing" Allows a Good View of the Back of the Voice Box

A simple maneuver to view the back of the voice box is "sniffing." When sniffing, vocal folds are open allowing viewing of the back of the voice box, facilitating the detection of vocal fold granuloma(s) which are usually located there (i.e., over the arytenoid cartilages).

1. Granuloma formation can also occur, rarely, above the opening of the vocal folds (supraglottic larynx), or below their (subglottic larynx).

2. Number of vocal fold granulomas: Granulomas may occur on one vocal fold (unilateral) or both (bilateral).

   1. One-sided or unilateral granulomas: Even when granulomas are one-sided, the opposite vocal fold often has some type of inflammatory reaction characterized by redness or swelling.
   2. Two-sided or bilateral granulomas: These usually occur directly opposite one another. This type of symmetrical effect occurs for two reasons:
      • The granuloma that begins on one vocal fold serves as an irritant to the other side when the vocal folds come together during speaking, coughing, or straining.
      • The trauma or irritant (e.g., stomach acid or endotracheal tube) that incites the initial inflammatory response often affects both vocal folds simultaneously.
3. Physical signs or clues as to possible causes of vocal fold granuloma: Careful observation of all parts of the voice box is necessary in order to assess granulomas, possible causes of these granulomas, as well as other voice disorder conditions present at the same time.

   For example, clues suggestive of backflow of stomach fluids to the voice box area (laryngopharyngeal reflux) that can be detected on visualization are:

   1. Redness or erythema
   2. Swelling or edema
   3. Excess mucous production
4. Physical signs or clues to other conditions also present which complicate the voice disorder from vocal fold granuloma (compounding conditions): Possible other conditions that might be present at the same time, and which could also significantly affect the voice as well as contribute to vocal fold granuloma formation through the compensatory response to said conditions, are:

   1. Vocal fold atrophy
   2. Vocal fold scar
   3. Vocal fold paresis

   If these other conditions which complicate a patient's case are present but not identified, management of the voice disorder is incomplete – the vocal fold granuloma most likely will not be successfully treated or rapidly recur.

Key Information

Straightforward Identification of Vocal Fold Granuloma Facilitates Treatment

The identification of vocal fold granuloma is usually straightforward. Patient symptoms, case history, and proper visualization usually result in the correct diagnosis and allow an otolaryngologist to determine the best course of treatment.

Symptoms

Treatment