Understanding 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 (xd) 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

A vocal fold granuloma is a non-cancerous growth on the vocal fold made up of inflammation tissue in response to irritation or injury. A variety of causes of irritation to the voice box have been associated with vocal fold granuloma, such as: backflow of stomach fluids (reflux), excessive forceful contact of vocal folds with voice overuse or misuse, and use of breathing tube.

Vocal fold granulomas are most likely to form in the back of the vocal folds, especially over the voice box cartilages that open and close the vocal folds or arytenoid cartilages. They have also been detected in other parts of the voice box:

• Above the vocal fold or supraglottic larynx
• Below the vocal folds or subglottic larynx
• In the vibrating-region of the vocal folds or musculomembranous vocal fold

Vocal Fold Granuloma	Normal Vocal Folds
A granuloma (gr) is detected as a yellowish growth covering the right arytenoid process. Irritation from reflux of stomach fluids into the voice box is also detected with redness and swelling in vocal folds (vf) and false vocal folds (f vf) and pachyderma or thickening of tissue in the back of vocal folds.	In contrast, a normal voice box (larynx) does not have any growths, and does not exhibit redness, swelling, or any thickening of the surface cover.
(click photographs for larger images)

NOTE: This chapter deals with the more common vocal fold granulomas over the vocal process of the arytenoids caused by one, or combination, of the following: 1) breathing tube; 2) forceful contact from voice misuse or overuse; 3) backflow of stomach fluids to the voice box area (laryngopharyngeal reflux).

There are three main causes of vocal fold granuloma.

1. breathing tube-induced trauma
2. forceful contact during voice overuse/misuse or constant coughing
3. irritation or injury of voice box surface lining (mucosa) from backflow of stomach fluids to the voice box (laryngopharyngeal reflux)

When more than one cause is present, the risk of developing vocal fold granuloma is increased.

Breathing tubes (endotracheal tubes) are passed through the nose or mouth, and down the throat, through the voice box, into the windpipe to provide adequate breathing during general anesthesia (being put "asleep" for surgery, etc.) or direct passageway to the airway for those requiring machine-assisted breathing (artificial ventilation) to breathe.

Once inserted, the breathing tube moves as the patient breathes, swallows, or coughs. This movement causes irritation which may lead to granuloma formation.

Key Information

Though there is no way to predict whether a breathing tube will result in granuloma formation, some physicians now believe that the co-existence of backflow of stomach fluids to the voice box area (laryngopharyngeal reflux) significantly increases the likelihood that a breathing tube may cause granuloma.

Forceful contact of the arytenoid cartilages (see Anatomy & Physiology of Voice Production) can occur during screaming, in the vocal habit of forceful starts to phonation ("coup deglotte"), repeated throat clearing, or coughing.

Initially, redness and swelling (inflammation) develop around the vocal folds, followed by the eventual development of vocal fold granuloma in some cases.

Backflow of stomach acid and enzymes into the voice box (laryngopharyngeal reflux), can also cause or contribute to granuloma formation. Exposure to stomach acid can lead to direct inflammation and irritation of the lining of the voice box (laryngeal mucosa) – which may then cause or contribute to granuloma formation. Additionally, irritation from LPR can lead to excess mucous formation, which then leads to throat clearing and chronic cough – both of which may contribute to the formation of a granuloma.

Any foreign body in the voice box can irritate the vocal folds and result in granuloma formation at the site around the foreign body.

Implants such as Teflon and other materials can be surgically placed into the larynx to help position the vocal folds to improve vocal fold function and hence achieve better voice. These implants can then lead to side effects such as granuloma information. Teflon is no longer recommended as medialization material because of its observed tendency to cause granuloma formation (Teflon granuloma).

Due to granuloma formation as a potential side effect of synthetic implants, and considering the advantages and disadvantages of synthetic versus natural (fat and collagen) substances as surgical implants, the ideal medialization material continues to be studied.

Granulomas can form in patients with tuberculosis, fungal infections, syphilis.

Blunt trauma may cause injury, which then results in an injury healing response (inflammatory reaction) that can lead to granuloma formation.

Key Information

Otolaryngologists are not certain why some individuals with these risk factors (reflux, surgical implants) develop granulomas while others do not. They hypothesize, however, that the existence of multiple risk factors

Who is likely to develop vocal fold granulomas?

Vocal fold granulomas are more common in adults than in children. As listed in the table below, certain groups of individuals also appear to be at greater risk for this condition than others.

Individuals at Increased Risk for Vocal Fold Granuloma Group Risk Factors Middle-age males Backflow of stomach fluids to voice box (laryngoesophageal reflux) Excessive talking Working under stress Religious leaders Working under stress Certain uses of voice: sermons, singing Improper speaking technique Weight lifters Grunting when lifting heavy objects Heavy duty machinists/mechanics Strain, grunting when lifting, tightening or pulling objects
	Highlights	Symptoms