Contact granuloma (1 of 2)
Contact granuloma right posterior vocal cord. Note bi-lobularity and surrounding inflammation (erythema).
Contact granuloma (2 of 2)
Same patient, as cords are arriving at phonatory contact. The medial surface of the left arytenoid cartilage will fit into the cleft between the two lobes of the contact granuloma.
Contact granuloma (1 of 11)
Breathing position shows classic large bi-lobed granuloma. Note the deep cleft (arrows), into which the right (left of image) vocal process (dotted line) will fit during voicing, which will leave one lobe above and one below the level of the cords.
Contact granuloma (2 of 11)
When the patient is asked to exhale rapidly, the granuloma displaces upwards (toward the camera), indicating that this granuloma is pedunculating (narrowing at its base) as a part of the process of maturation.
Contact granuloma (3 of 11)
The instant before full closure for phonation. The inferior lobule will descend slightly and the granuloma as a whole will rotate anteriorly so that the right vocal process can fit into the cleft between the two lobes. (That is, A will match A, and B match B; note that the B points here are further apart than they appear to be.)
Contact granuloma (4 of 11)
Phonation. Full adduction is still possible, but only the granuloma’s upper lobe is seen. This voice sounds virtually normal, due to how deep the granuloma’s cleft is, which allows the cords to fully meet each other, and also the fact that this granuloma doesn’t interfere with the vibrating part of the vocal cords (the anterior two-thirds, in clear view here).
Contact granuloma, 2 months later (5 of 11)
Same patient, two months later. Without any intervention, the inferior lobule has spontaneously detached. In this inspiratory (breathing in) view, the remaining lobule is drawn inward and slightly downward. The dotted lines indicate where the stalk will continue to pinch inward and narrow before spontaneous detachment.
Contact granuloma, 2 months later (6 of 11)
With exhalation, the lobule is blown slightly upwards on its stalk.
Contact granuloma, 2 months later (7 of 11)
Phonation. This looks similar to image 4, but the second lobule hidden from view below the cords in image 4 is now not there at all.
Contact granuloma, 5 months later (8 of 11)
Same patient, another three months later. The upper lobule has now also detached, leaving only a bruise. This bruise can be surprisingly durable, almost like a “tattoo.”
Contact granuloma, one year later (10 of 11)
Another seven months later. The bruise is smaller but still visible.
Contact granuloma (1 of 3)
Contact granuloma, with a typical bi-lobed shape divided by a deep central cleft. Note also the inflammatory appearance of the granuloma.
Contact granuloma (2 of 3)
As the vocal cords approach each other for phonation, the right medial arytenoid (at dotted line) is poised to fit into the cleft of the opposing contact granuloma (at arrows).
Contact granuloma (3 of 3)
As the vocal cords now almost meet, the arytenoid fits into the granuloma cleft like a key in a lock. This contact of the arytenoid show clearly the reason for the cleft and bilobularity.
Large tumor, before removal (1 of 8)
Large tumor posterior right true cord (left of photo) with abnormality extending up onto posterior false cord (indicated by the black dotted line).
After tumor removal (2 of 8)
A week after surgical excision, revealing the lesion to be a benign verruca. The wound exposes some of the arytenoid cartilage (indicated by smaller dotted circle). The circumference of the entire excision is shown within the larger circle of black dots.
2 months after surgery (3 of 8)
2 months after surgical removal of the verrucous hyperplasia, granulation formation is well underway.
5 Months after surgery, a granuloma is seen (4 of 8)
Five months later, a granuloma is seen, but voice is normal because no vibratory tissue was removed from the anterior 2/3 of the cord, and the left vocal cord (right of photo) can fit into the deep cleft between the two lobes of the granuloma so that the granuloma does not keep the cords separated, as seen in the next two photos.
7 months after surgery (5 of 8)
Two months later, 7 months after surgery, the inferior lobule of the granuloma has begun to fall off.
Pedunculation (6 of 8)
Asking the patient to inspire suddenly draws the granuloma into the airway, and shows that there is significant pedunculation (pinching in at the base to a stalk rather than remaining a broad attachment)
One year after surgery (7 of 8)
Now one year after removal (photo 2), the lower lobe is gone, and the upper lobe nearly resolved.
15 months after surgery (8 of 8)
Now 15 months after surgical removal of the verrucous hyperplasia, the granulation tissue has gone through the pedunculation process and has detached, leaving behind a tell-tale “bruise” at its base. Note that there are flecks of presumed hyperplasia seen, and these will be addressed with a thulium laser in the videoendoscopy room.
Intubation injury (1 of 4)
Gross hoarseness was immediately evident after a surgical procedure involving endotracheal intubation. After a few months, this granuloma is evident. It appears to be pedunculated and attached only where indicated by the dotted line. The small "X" is for reference with photos 2 and 4.
Granuloma drawn into glottis (2 of 4)
Here, the granuloma is drawn downward into the glottis by the inspiratory airstream. The "X" is for reference with photos 1 and 4.
Phonation (3 of 4)
During phonation, seen at closer range, the granuloma rides upward and nearly fills the laryngeal vestibule.
Anterior commissure (4 of 4)
Closeup at the anterior commissure. Dotted line indicates anterior edge of the granuloma. The "X" is for reference with photos 1 and 2.
Granuloma detached (5 of 8)
A few months later, voice has improved. The granuloma has spontaneously detached. Pinkness remains.
Vocal cord blurring
During voicing under standard light, note that there is vocal cord blurring on the right cord (left of photo) far more than on the left (blurring is indicated by thin, black lines). This suggests that the left side (right of photo) is not vibrating well.
Open phase (8 of 8)
Open phase of vibration at the same pitch, showing that only the right cord (left of photo) vibrates.
Panoramic view (1 of 6)
Panoramic view of larynx, showing left contact granuloma (right of photo). Elsewhere, this has been removed twice, with prompt recurrence.
Upper and middle lobule, Cleft 1 (2 of 6)
Close-up of posterior commissure. Deep 'cleft 1' here separates upper (U) and middle (M) lobules of the granuloma.
Phonation (3 of 6)
During phonation, the right vocal process is settled deeply into 'cleft 1' and only the upper lobule (U) rides above the plane of the cords.
Lower lobule (4 of 6)
Here the patient is blowing out and rotating the granuloma upward to expose 'cleft 2' and the lower lobule (L).
Upper and middle lobule, Cleft 2 (5 of 6)
Again during phonation, but with right vocal process now settled deeply into 'cleft 2,' and now both upper and middle lobules (U, M) ride above the plane of the cords.
Tri-lobed (6 of 6)
Another view, now showing clefts 1 and 2, as well as all three lobes of the granuloma. The plan is to allow granuloma maturation and spontaneous detachment.
Contact granuloma (1 of 4)
This man was diagnosed elsewhere with a stubbornly persistent lesion of his right vocal cord (left of photo). It almost appears that the left cord (right of photo) may have had a similar lesion in the past, but is now healed.
Narrow band light (2 of 4)
Under narrow band light, the rolled border of the right-sided lesion (left of photo is better seen, as is the healed nature of the left vocal cord (right of photo).
Phonation (3 of 4)
During voicing, the left cord (right of photo) clearly fits into the cleft of the right sided lesion (left of photo).
One year later (4 of 4)
Nearly a year later, the granuloma is healed. Lesions like this usually eventually heal, but can take many months and even a year or more.