Vocal Fold Granuloma: Unresolved Issues
Timing and Length of Anti-Reflux Treatment With Proton Pump Inhibitors Before Considering Surgery
Proton pump inhibitors (PPIs) are the main class of medications used to treat backflow of stomach fluids to the voice box (laryngopharyngeal reflux).
The optimal length of time for taking PPIs before surgery is performed
remains to be established. Decisions should be made on a case-by-case
basis. (For more information, see Reflux Laryngitis.)
Voice
therapy is used to treat vocal misuse or abuse. Some otolaryngologists
question the effectiveness of voice therapy in the treatment of
granulomas, while others debate how long this therapy should be used
before other treatments are introduced.
Methodology for Resection of Vocal Fold Granulomas
While
laser-based resection is sometimes preferred since its intense heat
prevents the bleeding common in knife-based excision, it can damage
tissue and lead to scarring. "Cold steel" knife-based surgical
resection is usually preferred because the risk for scar tissue
formation at the surgical site is lower.
Role of Botulinum Toxin, Type A
Because injections of botulinum toxin, type A cause vocal fold immobility, they can increase the severity of
hoarseness and other vocal symptoms. Both patient and physician must
consider potential risks and benefits of botulinum toxin, type A
injections to help granuloma(s) heal.
Steroids are used to reduce inflammation. Steroid therapy of vocal fold granuloma is controversial for two main reasons.
- No conclusive evidence exists indicating that steroids benefit individuals with granulomas.
- There
is some disagreement about how steroids should be prescribed – via
topical inhalant, pill, or injection. In particular, topically applied
and injected steroids have the benefit of affecting a specific area of
the vocal fold, while pill-based steroids have a more systemic effect
throughout the body.
NOTE: Most patients find that the inhaled steroids are very irritating to the
throat and may therefore be detrimental to the treatment of vocal fold
granulomas.
Furthermore, the question as to when to
prescribe steroids remains unanswered. Some otolaryngologists believe
these medications should be used early on in the treatment of
granulomas, whereas others feel treatment for underlying causes (such
as anti-reflux therapy or voice therapy) should be used first. |
