A vocal cord granuloma is a benign growth that forms on the vocal cords due to irritation or trauma from vocal use or acid reflux. It causes hoarseness, voice breaks, and a sensation of something in the throat. Treatment involves controlling acid reflux through diet, medication, and voice therapy to address harmful vocal behaviors. Surgery is usually a last resort as granulomas often resolve with proper medical management and lifestyle changes to avoid further irritation and trauma to the vocal cords.

1. Vocal Cord Granuloma Dr. Ornouma Sriwanishvipat MD, ENT Otorhinolaryngologist Voice Surgeon (Transgender) Snoring, Nose, Sinus Surgeon Yanhee International Hospital Charansanitwong, Bangok, Thaiand Website: dr-ornouma.com Email: [email_address]

2. What is a granuloma? A granuloma is a benign growth that results from irritation or trauma. It is usually found at the back of the vocal fold. Because there is little overlying soft tissue for cushioning, it is prone to trauma from impact with the vocal process of the opposite vocal fold when the folds come together. This happens during regular speaking, and even more forcefully during loud speaking or singing, throat-clearing, and coughing.

3. A granuloma is growing over the vocal process of the vocal fold on the right of this picture. This view of closing vocal folds shows clearly how the granuloma is further traumatized when the folds come into contact. What is a granuloma?

4. The area around the vocal process may also become irritated from the breathing tube routinely placed through the vocal folds during general anesthesia. This creates a special type of granuloma known as an intubation granuloma, which tends to grow in the days and weeks after the general anesthetic. Because these are not related to voice behavior, they are generally less stubborn than granulomas that arise spontaneously.

5. There is very good evidence that laryngopharyngeal reflux , an important source of irritation in the larynx, contributes significantly to the formation of a granuloma.

6. What are the symptoms of a granuloma? Commonly, a granuloma causes a sensation of something in the throat , hoarseness and voice breaks . The first of these symptoms can be especially troublesome, as it is likely to provoke throat clearing or coughing which can worsen the irritation which causes the granuloma in the first place. This gives rise to a cycle of irritation and granuloma formation which can be hard to break.

7. Voice symptoms generally result from the mass of the granuloma. In such a situation, hoarseness is typically breathy, and it is difficult to raise the volume of the voice. Again, a cycle may begin in which a person may try harder and harder to speak loudly, thereby increasing vocal fold trauma and worsening the granuloma. If the granuloma is attached to the vocal fold by a stalk (see figures 2 and 3), it can flip in and out of the way of the vocal folds and cause intermittent voice breaks rather than out-and-out hoarseness. What are the symptoms of a granuloma?

8. What are the symptoms of a granuloma? Figures 2 and 3: This large granuloma is attached to the vocal fold by a stalk, and moves up and down in the airstream during breathing.

9. A granuloma is one of the few vocal fold growths that can cause pain. This can be sharp during coughing, swallowing or throat clearing when the granuloma is directly irritated. Occasionally, the pain can be felt in the ear on the side of the mass. This phenomenon is known as “referred pain,” and results from the pattern of sensory nerves in the head and neck. What are the symptoms of a granuloma?

10. What does a granuloma look like? A granuloma is usually a reddish or pale lesion that occurs at the characteristic location over the vocal process. It can resemble a mound of tissue raised from the surrounding mucosa. A granuloma may grow to be quite large, forming a smooth spherical mass as in figures 2 and 3 above. It can be either broad-based or narrow-necked. Sometimes, there is a cleft in the mass created by repeated impact of the edge of the opposite vocal fold. Granulomas tend to grow until the causes of irritation are addressed. Occasionally a granuloma will become so large that it will outgrow its blood supply and slough off. This is no solution; however, as the factors that caused it in the first place will likely cause another

11. How is a granuloma treated? Aggressive steps to control reflux , including changes in diet and eating behavior as well as anti-acid medication, are always helpful. Often, medication must be taken in high doses, in excess of those recommended for routine control of reflux, and for up to several months. There is no evidence that antibiotics are helpful in most cases.

12. How is a granuloma treated? Voice therapy aimed at correcting behaviors that cause vocal fold trauma, such as habitual loud-talking or throat clearing, is as important as treating reflux. People generally underestimate the effect and importance of such behaviors, and most stubborn cases of granuloma result from poor control of these factors.

13. How is a granuloma treated? Surgery is generally a treatment of last resort, as most granulomas will shrink and eventually disappear with proper medical measures and behavioral changes. Surgical removal can be used in cases where a very large granuloma is likely to take a long time to resolve in order to reduce symptoms while treatment takes effect. Surgery without other treatment results in recurrence of the granuloma in the majority of cases.

14. Too often, surgical removal is used as a ‘quick fix’ for granulomas, because it is considered to be easier than treating reflux and changing harmful vocal behaviors, both of which require discipline and patience. Surgery is a poor substitute, however, as most granulomas grow back. Determined non-surgical treatment, on the other hand, can avoid the need for surgery altogether.

15. Thank you very much! Khop khun ka!