MDL - Vocal Fold Granuloma

Considerations

• For Dr. Jiang and Dr. Durr

  • See Chapter 19 of the book Operative Techniques in Laryngology (2008) by Rosen and Simpson

  • Anatomy 

    • Arytenoid 

      • Vocal process

  • Indications

    • Airway obstruction

    • Rule out malignancy

    • Rule out infection

    • Persistence despite medical therapy

• 2013: Recurrent Contact Granuloma Experience With Excision and Botulinum Toxin Injection

• 2014: Vocal process granulomas: a systematic review of treatment

Preparation

• • For the basic preparation, see the Micro-Direct Laryngoscopy - basic page

  • Special equipment 

    • May need the Pilling posterior commissure laryngoscope 

  • Ask the anesthesiologist 

    • "Small" ETT - size 5 

Procedure

• • Think atraumatic 

  • Think exposure 

    • Position the ETT anterior to the laryngoscope, either by 

      • using the Pilling posterior commissure laryngoscope  - or - 

      • angling the ETT so that it enters the glottis from the opposite side as the laryngoscope

    • Goal: View posterior to the ipsilateral mid-membranous VF and the entire arytenoid / posterior glottis

  • Suspend

  • Inspect and palpate

    • Identify the stalk - a curved alligator (curved away from the side of the lesion) can be helpful

  • Remove

    • Hold the lesion at its stalk with the curved alligator 

    • Retract toward the midline 

    • Transect the stalk with the curved microscissors 

  • Hemostasis 

    • topical 1:10,000 Epinephrine soaked pledgets 

  • Re-examine 

    • Remove any residual tissue using 1 mm cup forceps 

• Optional

  • • Vocal fold augmentation

    • Vocal fold Botox 

Sample operative report

Post-op

• • Voice rest for 1-2 weeks 

    • For Dr. Durr, use the the University of Texas Voice Rest protocol here

      • See the smartphrase by J Gilde: JEGPIVOICERESTPO

• PPI and LPR lifestyle measures

  • Complications

    • Recurrence 

    • Arytenoid cartilage injury 

Pearls & Pitfalls

High-Yield

• • Pathophysiology 

    • VF granulomas result from perichondritis of the arytenoid (intubation, LPR, voice abuse - underlying glottal insufficiency) 

Links

• eMedicine - Contact Granulomas