Prediction of the efficacy of proton-pump inhibitors in patients with contact granuloma using 24-hour combined dual channel pH/impedance monitoring.

OBJECTIVES: We aimed to evaluate the treatment outcomes of proton-pump inhibitors (PPIs) in patients with contact granuloma (CG) and to investigate the parameters of 24 h combined dual channel pH/impedance (24 h pH/MII) monitoring, which are reliable for predicting the response to PPI of CG patients. METHODS: We reviewed the medical records of patients with CG who had been treated with PPIs and had completed more than 6 months of follow-up. We classified the patients into two groups (cured vs. persistent), according to their PPI treatment outcomes. Reflux events were categorized into three groups based on pharyngeal pH during reflux: 1) acid reflux (pH < 4), 2) weak acid reflux (4 < pH < 7), and 3) weak alkaline reflux (pH >7), as detected by a proximal probe. We compared the results of 24h-pH/MII between the two groups and used receiver operating characteristic curve (ROC) analysis to determine the cutoff values of significant parameters for predicting responses to PPIs. RESULTS: Among 22 patients who completed at least 6 months of PPI treatment and follow-up, weak acid reflux events were more frequently observed in persistent group than in the cured group (p = 0.046), and the proportion of weak acid reflux was also higher in the persistent group (p = 0.031) than in the cured group. Reliable parameters predictive of a poor response to PPIs were a number of weak acid reflux events ≥ 11 (area under the curve [AUC], 0.775; p = 0.03) and a proportion of weak acid reflux events ≥ 56.7 % (AUC, 0.763; p = 0.038) in ROC analyses. CONCLUSION: Weak acid reflux was identified as a significant factor associated with the treatment outcomes of PPIs in patients with CG. A number of weak acid reflux events ≥ 11 is considered to be the most reliable predictor of a poor response to PPIs in patients with CG.

Thyroarytenoid botulinum toxin injection for refractory laryngeal contact granuloma.

BACKGROUND: Although there are many treatments for laryngeal contact granuloma (LCG), some patients still fail treatment. Botulinum toxin A injection vocal cords may be a salvage therapy. OBJECTIVES: To study the efficacy of thyroarytenoid botulinum toxin A injection for the treatment of refractory LCG. MATERIAL AND METHODS: From May 2021 to March 2022, 23 male patients with refractory idiopathic LCG were treated by injection of botulinum toxin A into the thyroarytenoid muscle via the thyrohyoid membrane approach. Inspiratory-phase laryngoscopy images were collected before treatment and 3 months after injection treatment. The lesion size was evaluated with the Farwell granuloma endoscopic grading system and Image J software. RESULTS: The average age of 23 patients was 49 years. The dose of botulinum toxin injection ranged from 2.5 to 5 units. Three months after injection, 17 patients were cured, 2 patients showed marked improvement, and 4 patients did not experience any effect. The total efficacy rate was 82.61% (19/23), and no serious complications occurred. Almost all patients experienced hoarseness within one week after injection; they gradually recovered after one month, and their voice returned to baseline at 3 months. CONCLUSIONS: Thyroarytenoid botulinum toxin injection is an effective method for resolving refractory LCG.

Short-term outcome of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females.

OBJECTIVE: To evaluate the short-term efficacy of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females. METHODS: A total of 14 female patients with laryngeal contact granuloma treated in our outpatient department from November 2017 to January 2020 were included in the study. Inspiratory-phase laryngoscopy images were collected before treatment and 1 month after each injection, and the lesion size was measured and evaluated with ImageJ software. RESULTS: Two patients achieved complete remission after one injection, with a percent reduction of 100%. After two injections, 4 patients achieved complete remission, with a percent reduction ranging from 96% to 100%. After 3 injections, 4 patients achieved complete remission (including one patient with bilateral lesions), and the percent reduction ranged from 95% to 100%. Three patients achieved incomplete remission, with a percent reduction of 46%, 55%, and 81%, respectively. In one case, there was no remission, and the granuloma increased in size after treatment. CONCLUSION: In women with laryngeal contact granuloma, transcutaneous glucocorticoid injection therapy can quickly resolve the granuloma in a short period.

Comparison of PPI and combined treatment in the treatment of recurrent laryngeal contact granuloma.

OBJECTIVE: To compare the therapeutic effect of PPI and combined treatment in the treatment of patients with recurrent laryngeal contact granuloma. METHODS: The clinical data of 299 patients with recurrent laryngeal contact granuloma treated with PPI or combined treatment (PPI with glucocorticoid injection into granuloma by the thyroglossal approach) from February 2013 to June 2019 were analyzed retrospectively. Patients were divided into two subgroups: PPI and combined treatment. The cure rates, recurrence rates and cure time of the two subgroups were compared and analyzed separately. Than we can get the optimal treatment of the two treatment in the treatment of recurrent patients. RESULTS: In recurrent patients, the cure rate (81.20%) and recurrence rate (3%) of combined treatment were superior to those of PPI (57.58%) and recurrence rate (12.12%); (P < 0.05). The cure time of PPI was longer than that of combination therapy (P < 0.001). CONCLUSION: The therapeutic effect of combined treatment is better than that of PPI in patients with recurrence. At the same time, combined treatment is an effective treatment for recurrent granuloma and can be used as a first-line treatment for recurrent laryngeal contact granuloma.

Unusual extra-podal fungal mycetoma with black grains in a Senegalese child.

Mycetoma remains endemic in the tropical and subtropical regions of the "mycetoma belt" including Senegal. It affects more commonly young men in the age group of 20 to 40 years. The foot represents the most commonly affected site. The most common extra-podal localizations are leg, knee, buttocks, hand and arm. We report an exceptional case of cervical fungal mycetoma that occurred in a 13-year-old Senegalese child. He consulted for a cervico-submandibular tumefaction with multiple sinuses and black grains discharge evolving since 6 years, associated to laryngeal dyspnoea. Mycological examination with culture isolated Madurella mycetomatis. Cervical CT Scan showed bone and soft tissue invasion. Terbinafine alone was administered. During the evolution, tracheotomy was performed following the aggravation of the laryngeal disorders. Death from severe sepsis occurred after 8 months of evolution. The particularities of our case are the occurrence of fungal mycetoma in a child, the cervical localization and the difficulties of therapeutic management largely due to the diagnostic delay.

Interarytenoid botulinum toxin A injection for the treatment of vocal process granuloma.

OBJECTIVES: To report on the efficacy and adverse effects of interarytenoid botulinum toxin A injection for the treatment of vocal process granuloma. METHODS: A retrospective chart review was conducted of eight patients with vocal process granuloma resistant to anti-reflux therapy who underwent interarytenoid botulinum toxin A injection. The mean dosage of botulinum toxin A injected was 6.56 U. RESULTS: Fifty per cent of patients had complete regression of the lesion and 50 per cent had partial regression. The main side effects were breathiness (n = 4), voice breaks (n = 1) and aspiration (n = 1). CONCLUSION: Interarytenoid botulinum toxin A injection for the treatment of vocal process granuloma is an effective mode of therapy, with transient vocal and swallowing side effects.

Treatment of Laryngeal Granulomas

Abstract Introduction Laryngeal granulomas are benign, recurrent lesions of many causes (reflux, voice abuse, intubation, and idiopathic), which renders its treatment difficult. Objective To describe our experience in the treatment of laryngeal granulomas. Methods From 16 medical records of the patients with laryngeal granulomas seen between 2010 and 2017 in a university hospital, the following data were analyzed: age, gender, vocal and gastroesophageal symptoms, vocal overuse, intubation, treatments, videolaryngoscopy before and after the treatment. Results Gender: female, 10; male, 6. Age: between 20 and 60 years old (11%). Etiology of the granulomas: intubation (9), reflux (4), idiopathic (3). The initial treatments adopted in all cases were: inhaled beclomethasone dipropionate 100 μg 12/12 hours (1month), proton pump inhibitor, omeprazole 40 mg/day (2months), and dietary and voice education. After this period, 10 patients (7 postintubation, 3 idiopathic) were submitted to surgery, since no improvements in the symptoms or in the lesions were seen. Of these, two recurred, requiring a second surgery, one of which recurred six times and received botulinum toxin A. Only one patient with granulomas due to laryngopharyngeal reflux presented no improvement in the symptoms nor in the lesion after the pharmacological treatment and had been submitted to microsurgery. All of the other patients with reflux granulomas were successfully treated with the drug treatment, and the longest treatment time for complete remission of the symptoms and of the lesions was 9 months. Conclusions In laryngeal granulomas caused by reflux, treatment with inhaled steroids and proton pump inhibitors proved to be effective, although prolonged. In postintubation and idiopathic granulomas, surgery was the best treatment.

Botulinum Toxin Injections Into the Lateral Cricoarytenoid Muscles for Vocal Process Granuloma.

OBJECTIVE: Contact granulomas are benign, exophytic inflammatory lesions of the larynx that typically arise on or near the vocal process of the arytenoid cartilage. The most common management options include voice therapy and antireflux pharmacotherapy, intralesional steroid injections, botulinum toxin injections, and surgical excision. In-office Botox injection into the lateral cricoarytenoid (LCA) muscle can be effective even for recurrent granulomas. STUDY DESIGN: This is a retrospective chart review and literature review. METHOD: We reviewed more than 400 charts and included two patients, who underwent in-office injection with botulinum toxin A into LCA muscles bilaterally, after previously failing both conservative and surgical management. RESULTS: Both cases showed significant improvement of the laryngeal granulomas after 6 months and a single botulinum toxin injection. Both cases were initially grade III granuloma that improved to grade I. CONCLUSIONS: In-office injection of botulinum toxin A targeting the LCA muscle appears to be a safe and effective treatment modality in refractory laryngeal granuloma.

Role of lifestyle modifications for patients with laryngeal granuloma caused by gastro-esophageal reflux: comparison between conservative treatment and the surgical approach.

CONCLUSIONS: It is considered that a regimen combining pharmacologic management and lifestyle modifications is the most effective treatment for laryngeal granulomas caused by GER. OBJECTIVES: This study compared the results of the combination therapy and surgery to determine the best treatment of laryngeal granuloma caused by gastro-esophageal reflux in 51 patients. METHODS: Prospective study. RESULTS: In the conservative treatment group, the CR rate was 89.7% and recurrence rate was 2.6%, while the lesions remained in patients (7.7%). This study compared the CR and recurrence rates between conservative treatment and surgery for granuloma. The results showed that the laryngeal granuloma recurrence rate was significantly lower with the conservative treatment regimen compared with surgery (p = .0016).

The results of Kaplan-Meier and multivariate analyses of etiological factors related to the outcome of combined pharmacological therapy against laryngeal granuloma.

CONCLUSIONS: The present results indicate that the diagnosis of gastroesophageal reflux disease (GERD) is an independent etiological factor predicting retardation of the resolution of laryngeal granuloma. OBJECTIVES: To assess the effects of combined usage of an inhaled corticosteroid plus tranilast and/or a proton pump inhibitor on the size of granulomatous lesions, and to reveal etiological factors related to the outcome using the Kaplan-Meier method and a subsequent multivariate analysis. METHODS: Sixty-two patients with laryngeal granuloma were enrolled. An inhaled corticosteroid plus tranilast (300 mg/day) and rabeprazole (20 mg/day) were administered to all of the patients, and only to those diagnosed to have GERD, respectively. The size of granulomatous lesion was measured for each patient at the initial visit and every 4 weeks. At 48 weeks, the Kaplan-Meier plots for lesion disappearance rate were compared between groups with and without each of the etiological factors, followed by Cox proportional-hazards regression. RESULTS: The 48-week lesion disappearance rates for the whole population were 82.3%. Although the Kaplan-Meier analysis exhibited significant differences between patients separated by GERD diagnosis, phonotrauma, and habitual smoking, only GERD were identified as a real independent etiological factor affecting the resolution of the lesion by a multivariate analysis using Cox's proportional-hazards regression.

[Analysis of the curative effect of intralesional steroid injection combined with acid-suppressive therapy for laryngeal contact granuloma].

OBJECTIVE: To study the efficacy of intralesional steroid injection combined with acid-suppressive therapy for laryngeal contact granuloma. METHODS: Eighty eight patients with laryngeal contact granuloma diagnosed from March 2010 to October 2014 were reviewed.Twenty-one patients took intralesional steroid injection combined with acid-suppressive therapy as experimental group (4 patients in initial treatment group, 17 patients in non-initial treatment group), other 67 patients only received acid-suppressive therapy as control group. The clinical data of these patients was analyzed. RESULTS: In experimental group, 15 patients were cured (71.43%) and the average cure time were (3.80±0.43) months, total injection time was 2-6 times and the median was 3 times. In control group, 50 patients were cured (74.63%) and the average cure time were (5.31±0.38) months. No any systemic and local complications were found in all the patients during the follow-up period of 6-42 months. The cure rate had no significant difference between the experimental group and control group, but the cure time in the former group was shorter than that in the latter group (Z=-2.093, P=0.036). In the experimental group, the initial treatment patients had no significant difference in cure rate and cure time compared with non initial patients (χ(2)=1.112, P=0.544; Z=0.000, P=1.000). CONCLUSION: Intralesional steroid injection combined with acid-suppressive therapy can be recommended as a safe and effective alternative therapy for laryngeal contact granuloma, especially the refractory granuloma.

Vocal process granulomas: a systematic review of treatment.

OBJECTIVES: Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences. DATA SOURCES: The data came from a systematic review of the literature. METHODS: Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment. RESULTS: The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences. CONCLUSIONS: There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.

Interarytenoid botulinum toxin injection for recalcitrant vocal process granuloma.

OBJECTIVES/HYPOTHESIS: This study evaluated the efficacy of botulinum toxin type A injected into the interarytenoid muscle to treat recalcitrant vocal process granulomas. STUDY DESIGN: Retrospective clinical review at a tertiary care center. METHODS: Eight patients with vocal process granulomas refractory to a variety of prior treatments including surgical resection, proton pump inhibitor therapy, and voice therapy underwent percutaneous injection of botulinum toxin type A into the interarytenoid muscle, performed in an office setting. Doses ranged from 5 U to 25 U in one to two injections. RESULTS: One patient demonstrated no improvement, two patients demonstrated partial resolution, and five patients demonstrated complete resolution of their granulomas. Four patients noted transient breathiness. There were no other side effects. All patients tolerated the injections without difficulty. CONCLUSION: Botulinum toxin injection into the interarytenoid muscle appears to be a safe and effective modality for treating recalcitrant vocal process granuloma.

Zinc sulfate therapy of vocal process granuloma.

Vocal process granuloma is a benign lesion that occurs on the arytenoid cartilage. It tends to recur locally, and there is a great diversity of methods to treat it. Here, we reviewed the effects of zinc sulfate therapy program in 16 patients with vocal process granulomas. Eleven patients had a history of trauma or laryngeal intubation and five patients had unknown origin. Eleven had recurrence after one to three failed surgeries, and the others had no prior treatment. Symptoms included hoarseness, sore throat, lump sensation in the throat and cough that apparently improved. The granulomas did not recur for at least 1 year. No complications occurred. For vocal process granuloma, zinc sulfate therapy is good either as an initial or compensatory treatment.

Inhaled triamcinolone with proton pump inhibitor for treatment of vocal process granulomas: a series of 67 granulomas.

OBJECTIVES: We sought to analyze the outcomes of vocal process granulomas treated with proton pump inhibitors and inhaled triamcinolone acetonide. METHODS: We reviewed the medical records of patients with a diagnosis of contact granuloma or vocal process granuloma between 1995 and 2008. Data included age, gender, intubation history, reflux history, lesion location, previous treatment methods, treatment course, and recurrence. All patients were treated with daily or twice-daily protein pump inhibitors and inhaled triamcinolone acetonide (300 microg 3 times a day). RESULTS: Sixty-seven granulomas were diagnosed in 54 patients: 13 bilateral and 41 unilateral. Twenty patients, including all 11 women, had a recent history of intubation. Sixty-two granulomas in 50 patients were treated with triamcinolone and a proton pump inhibitor. Of the 57 granulomas that completed treatment, 5 (9%) did not respond (mean follow-up, 50 weeks; range, 30.3 to 78.3 weeks), 13 (22%) partially responded (mean follow-up, 11 weeks; range, 3 to 30 weeks), and 40 (69%) completely responded (mean follow-up, 21 weeks; range, 5.9 to 84.6 weeks). Three cases had recurrence: 2 nonresponders and 1 complete responder. One patient developed oral thrush. CONCLUSIONS: In this study, vocal process granulomas occurred more frequently in men, whereas women developed granulomas only after intubation. The anti-inflammatory action of inhaled triamcinolone combined with antireflux proton pump inhibitors successfully treats most vocal process granulomas with low rates of side effects and recurrence.

Botulinum toxin as adjunctive therapy in refractory laryngeal granuloma.

OBJECTIVE: This study evaluated the role of botulinum toxin type A in the treatment of refractory laryngeal granulomas. STUDY DESIGN AND SETTING: Retrospective clinical review at a tertiary care hospital. Seven patients with vocal process granulomas underwent percutaneous injection of botulinum toxin into both vocal folds, performed in an office setting. Total doses ranged from 10 to 25 U, divided between both vocal folds. RESULTS: All patients experienced resolution of their granulomas over two to seven weeks. No patient developed aspiration pneumonia. All patients experienced hoarseness secondary to the injections, but voice quality returned to baseline in all patients as the toxin was degraded. CONCLUSIONS: Botulinum toxin is safe and effective therapy in resolving vocal process granulomas in patients refractory to traditional therapy. The optimal treatment dose remains to be determined. SIGNIFICANCE: Percutaneous botulinum toxin injection is helpful in resolving laryngeal granulomas.