Hello, I'm Dr. Robert Bastian. My purpose is to discuss a family of conditions called, variously,
contact granuloma, contact ulcer, intubation granuloma. While these kinds of lesions are
not ominous, if you don't understand them as a patient or as a physician, they can cause a lot
of needless worry and expense. My purpose is to address this subject purely as an educator–to
help you be more effective in working with your personal physician. We need to first set the stage
with some background information, so let's do that. First, the larynx or voice box here, is in
the middle of the neck right here, and from the inside, you can see that the vocal fold lives
inside this way. It goes front to back, and it has a partner on the other side. We're going to
be talking about injury that occurs back here, in the back. And let me show you one example of that
right here. So here you see vocal folds are in this parallel anterior posterior position, but
here's a granuloma on the back of the vocal fold right there. That's our subject. Now, the
vocal folds separate, like so, for breathing and they come together for voice making and
also, when we cough or throat clear, there's a lot of collision. They bang together at the back, no
sympathy needed, because they're built for this. Now, the anterior–two-thirds–of the vocal folds,
that–let's make these the vocal folds like this, the anterior two-thirds has a lot of soft tissue,
it's very flexible and lots of soft tissue. But the posterior–one-third–has very little
tissue–overlying cartilage. And I think it's that very thin layer over the back end of the vocal folds,
that's the key, the thinness there. Now with that background, what about this family of granulation
tissue lesions, what are they? Well, they are benign tissue reactions or growths that occur in response
to injury on that back end of the vocal fold. When the thin layer of soft tissue called mucosa
is injured in one of several ways, (that I'll get to in a moment) the cartilage underneath/beneath
that, that surface tissue, becomes exposed and it–the body–then goes to work to try to heal that
injury. But in so doing, it sometimes seems not to know when to quit and it keeps heaping up healing
tissue that is called granulation. The result is a granuloma or "proud flesh." Now, I have a patient, a
farmer who told me one time that this can happen on the shoulder of a horse that scratches itself
against a fence–gets a little tiny wound. And then there's this little blob of pink tissue they call
proud flesh that results. Dentist's sometimes see something similar on the gums, where there's an
injury. Persons with tracheotomy can see it around the tracheotomy tube where the body is trying to
heal but the tube won't let it, and so it heaps up healing tissue. I even have seen them on the tongue
where someone inadvertently stabs the tongue and then that leads to a granuloma. Well, in the back
end of the vocal folds what is it that leads to the injury and the, and the granuloma response?
There are several things. One is the abrasion or the scrape that can be caused by a breathing
tube during general anesthesia. Those tubes are used thousands of times every day and normally
there's a little irritation and it resolves. But on a rare and somewhat unpredictable basis, even
with great anesthesia care, a little granuloma can follow. Now, what else can cause these granulomas
besides breathing tubes? Well, aggressive coughing. A person may have a severe, racking bronchitis during
which there was a lot of very aggressive coughing, and then a couple of months later they can come
in and we find a granuloma on the back end. In another group of people, we think that chronic,
aggressive throat clearing, that really kind of throat clearing can be a
cause, and some believe that chronic acid reflux. That is, acid burbling up from the stomach into the
throat at night during sleep can be a cause. So those are the common suspects, but in some cases
it doesn't seem like there is any real cause and then it's just occurred. Well, what are the signs
and symptoms that patients experience? Some people are virtually symptom free and the granuloma is
found during an examination that was done for another reason. So they may go see the doctor
with a sinus infection, the doctor happens to do a general exam and finds this little granuloma. Other
people come to the doctor and ask to be examined because they have a little sticking sensation like
a little print pinprick here, kind of right there. Others still have a vague sense of discomfort that
radiates to the angle of the jaw or even up to the ear if the granuloma becomes very large. It
can interfere with voice quality, though that's surprisingly infrequent. An example might be that
a person says, "I was sitting and reading and after a period of time the phone rang and I
pick up the phone and I go, 'h..hello?' and there's just this little tiny catch and then the voice is fine."
A few people have also commented that they coughed up a little tiny piece of tissue, and others have
said that that they've caught up little tinges of blood. So there's a range of patient experiences
and most, though not all of the time, symptoms are somewhat minimal or vague and they certainly are
variable between people. Well, how is the condition diagnosed? Two schools of thought; the traditional
thinking might be that a biopsy is necessary so that the pathologist can, can confirm that
the abnormal tissue is in fact just granulation. I give no argument to that if there's any question
at all about the diagnosis. But I typically, I'm in a second school of thought which says
rarely do you need to biopsy these lesions and that's because it seems to me with the current
availability of extremely high-resolution optics, visual criteria alone can be sufficient. Look at
the, the quality the, the, the amazing clarity of this kind of diagnosis where you can see the
lesion so clearly. Well, what are the criteria for visual diagnosis? It's the location in the back end
of the vocal fold, it's also the bi-lobularity, you see the two lobes, and sometimes it's tri-lobed.
Here's one right here that is tri-lobed. You see almost three different lobes right there. And when
the person phonates, almost always the vocal folds come together fully because the granuloma gets
out of the way above or below or half of it's above and half of it's below. So anyway, those are the
visual criteria, and when they're very strong I don't think there's a need for biopsy. Now some–
what about treatment? Some people think that–again, the two schools of thought–some people think that
you should remove it, and the, the concept is that you remove it not just for biopsy but because
somehow removing it will help the area to heal. Well, if you've heard what I've said so far, you
can see that the problem with that thinking is that removal just recreates the wound. Remember
that injury is what seems to have initiated the granuloma and so it shouldn't surprise us that
it recurs very commonly after removal, and that puts us right back where we started. And just
as an example, I saw a man many years ago who actually had his granuloma removed 12 times.
It would come back and they'd say "Well, let's remove it again." So that's in a nutshell, why I am with the
second school of thought: don't remove the lesion, but instead, recommend supportive things and
just surveil, just watch over time. You can do supportive things to try to facilitate healing,
but it's going to take many months time for that to happen and we don't worry about that. Well, what
happens while we just observe and wait for healing? The granulation tissue goes through a maturation process.
Initially it's attached on a broad-base and then, as it matures it gets bigger, and we say
"Good, you're making progress! It's good when it gets bigger." Because while it's getting bigger, it's also,
typically, pinching in at the base and it becomes pedunculated, which means attached by a stock, and
it starts to flip back and forth and then it finally spontaneously detaches, though again it
can take many months. Now as long as symptoms are negligible to absent during that time, no worry.
Just live with the little lesion and wait for healing. Well, the support of treatments I mentioned
minimize aggressive throat clearing or coughing and if there's any question about that acid reflux
problem we may prescribe medications to neutralize or stop production of acid. Now what if a person is
highly symptomatic with a lot of voice change, for example? Well, we can remove the lesion to help them
with those symptoms, but we intentionally leave a bit behind. We don't want to do a really good
job and and clean it completely out because we're going to re-expose the cartilage (or the
perichondrium). So we leave the stock or a little bit of the base of it. Another alternative is we
can inject steroid right into the granuloma in the voice laboratory and that will tend to shrink
it, generally, by about two-thirds, and symptoms then often diminish greatly or even go away. We can also
vaporize some of the granulation in the office with an office based laser such as a thulium or
pulsed KTP. Well let's summarize what we've talked about. Granulation tissue in the posterior larynx
is best thought of as exuberant healing tissue in response to injury. With modern equipment, visual
criteria are often sufficient for diagnosis, and re-examination at long intervals–generally three
to six months–is adequate. Supportive treatments–while we wait for healing–include trying to help
the person reduce the cause and throat clearing possible steroid rejection, injection–excuse me–or
very occasionally–in the highly symptomatic person–removal, but taking care to leave the
stock or the base of the granuloma untouched. Once again, this is an informational video
offered to help you work more effectively with your personal physician. Please do not consider
it medical advice that is necessarily applicable to you. Thanks for listening, and I hope this helps.