Contact Granuloma

A contact granuloma is a benign tissue reaction or growth, typically on the posterior third of the vocal cord, that occurs in response to injury. Contact granulomas are also known as contact ulcers, intubation granulomas, or “proud flesh.” This kind of chronically irritated tissue may be viewed as an exuberant healing response that “didn’t know when to quit.”

Sources of injury:

One type of injury that may lead to a contact granuloma is injury from an endotracheal tube, as the inserted tube presses and rubs against the posterior ends of the vocal cords. Another potential source of injury is chronic, aggressive coughing or throat-clearing. Yet another potential source is undergoing surgical procedures such as laser excision of a cancer. Some also believe that irritation from acid reflux can lead to a contact granuloma. In many cases, there is no obvious cause for the original injury.

The typical location of a contact granuloma:

Contact granulomas typically occur on the posterior third of the vocal cord, also known as the cartilaginous glottis. Unlike the other two-thirds of the vocal cord, this segment is inhabited by cartilage (namely, the arytenoid cartilage), and that cartilage is covered only by a relatively thin layer of perichondrium and a layer of mucosa. This thinly cushioned cartilage or perichondrium interface is particularly prone to being irritated and then responding with the exaggerated healing that produces a contact granuloma. Hence, most granulomas occur in this location.

Symptoms of a contact granuloma:

Some individuals with contact granulomas have no symptoms whatsoever and only discover they have a granuloma while being examined for some other reason. Others notice a sticking or pinprick sensation, or have some sense of vague discomfort in the area of the neck radiating upward towards the angle of the jaw. Occasionally, a person may develop a “catch” in the voice, such that it takes a second to begin speaking clearly. Very occasionally, when a bit of the granuloma detaches (see below), a person may cough up blood or a tiny piece of tissue. In general, symptoms are mild.

Treatment for a contact granuloma:

Some clinicians prefer to treat contact granulomas by removing them. However, the tiny injury or wound that results often produces a recurrent granuloma.

A better approach is simply to wait for the granuloma to detach of its own accord. This process of self-detachment, which may take several months, is like an apple maturing and then dropping from the tree: the granuloma continues to grow in size, and once it becomes big enough, the back-and-forth movement of air and the displacement caused by contact with the opposite arytenoid cartilage cause the granuloma to slowly pinch inward at its base and become more and more pedunculated; eventually, the connecting stalk can no longer support the granuloma, and the granuloma breaks free. For an example, see the photos below.

If, however, a person’s symptoms are too troublesome to wait for months, then the granuloma can be surgically removed, but while still leaving part of the stalk or base projecting from the surface, so as to avoid re-injuring the cartilage and perichondrium, which would provoke the formation of another granuloma.


Photos:

“Tattoo” of blood after detachment of intubation granuloma

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Intubation granuloma (1 of 5)

This woman was intubated for 5 days due to severe illness. Afterwards, she had no voice for several weeks. It has recovered nearly fully, but she was told elsewhere that there was a “growth” that needed to be removed.

Intubation granuloma (2 of 5)

In this closer view with forced inspiration, one can see that this is a granuloma, with point of attachment at arrows becoming pedunculated. Since granulomas typically mature, pedunculate (become attached by a progressively thinner stalk), and fall off on their own, she was advised to return in 4 months, at which point it would likely be gone.

Granuloma is gone (3 of 5)

4 months later: In this distant view, it appears that the granuloma has indeed detached. (Typically patients do not know when this happened; rarely, they cough out a pink piece of tissue and a bit of blood at the time of detachement.)

Blood tattoo (4 of 5)

In this mid-range view, a “blood tattoo” is seen where the pedicle detached from the granuloma (arrow). This “blood spot” often persists for months or years.

Blood Tattoo (5 of 5)

A closer view of the “blood tattoo.”

Contact granuloma

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Contact granuloma (1 of 2)

Same patient, after treatment with antifungal agent. Note residual haziness (Lab).

Contact granuloma (2 of 2)

Same patient, as vocal folds begin to come together for phonation, showing right fold fitting into the groove between the two lobes of the granuloma (Lab).
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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.

Intubation Granulomas Can Be Left Alone to Mature and Spontaneously Detach

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Intubation Granuloma (1 of 3)

Six months after a long intubation due to grave illness. When the patient exhales as shown here, his contact granulomas “blow” upwards from the level of the vocal cords. These granulomas are quite “mature” as can be seen in the next photo.

Intubation Granuloma (3 of 3)

Here, dotted lines are added to show where the granuloma will likely detach. Occasionally a patient will cough out a small piece of tissue with a small amount of blood. More often, the granuloma detaches outside of patient awareness.

Intubation Granuloma (2 of 3)

With the patient now breathing in, the granulomas are drawn downwards toward the trachea, and the pedicle or “stalk” to which it is attached becomes visible on the left side (right of photo). These particular granulomas are well along in the process of pedunculation, and typically detach spontaneously. It can take patience to wait this process out. If symptoms at any time during this wait are unacceptable (not usually the case), then the granuloma can be treated with laser ablation in a videoendoscopy laboratory or steroid injection into the abnormal tissue.

Contact Granuloma, Gradually Pedunculating and then Detaching

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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, “Key-in-lock Fit”

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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.

The Healing Sequence of Granulation

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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.

Vocal Cord “Tear” and Granuloma

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Intubation injury (1 of 8)

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 8)

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 8)

During phonation, seen at closer range, the granuloma rides upward and nearly fills the laryngeal vestibule.

Anterior commissure (4 of 8)

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 (6 of 8)

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.

Closed phase (7 of 8)

Low in the female range, at A3 (220 Hz), closed phase of vibration.

Open phase (8 of 8)

Open phase of vibration at the same pitch, showing that only the right cord (left of photo) vibrates.

TRI-Lobed Contact Granuloma

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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—Ulcer Type With Rolled Border

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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.

Evolution of Circular Tracheal Scar Including Granuloma

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Two weeks post-op (1 of 4)

Two weeks after removal of totally stenosed cricotracheal segment that and circular reanastomosis. Looking downward from the level of the vocal cords, the circular suture line is indicated with a dashed line. The point of origin of the granuloma is seen is at the *.

Six weeks post-op (2 of 4)

Six weeks after the crico-tracheal resection and reanastomosis, the patient’s breathing seems normal to him, including during vigorous workouts. Here on exhalation, note that there is a granuloma attached to the “scar” line anteriorly. As seen in the next photo, this granuloma is highly pedunculated and ready to spontaneously detach.

Inhaling (3 of 4)

The patient is inhaling here, and this has drawn the granuloma below the suture line. The pedicle (point of attachment) is indicated by the dotted line.

Rapid inhalation (4 of 4)

With rapid inspiration, the granuloma flutters, causing its blurring. Detachment within weeks is expected.

Granulomas Mature and Fall Off by Themselves, But Steroid Injection Can Help…

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"Third" granuloma (1 of 6)

This man has had a granuloma removed twice elsewhere. As expected it recurred both times, so that in a sense, this is the “third” granuloma. It has the typical bi-lobularity (U = upper; L = lower).

Injection into lower lobe (2 of 6)

Occasionally a steroid injection is used for the small percentage of persons with granuloma who are symptomatic. Here, note the needle inserted into the lower lobe (L, right of photo) to infiltrate triamcinolone.

Injection into upper lobe (3 of 6)

Now the needle has been redirected into the upper lobe (U). This procedure is done under topical anesthesia in the voice laboratory.

Five weeks later (4 of 6)

About 5 weeks later, the patient’s symptoms have gone away. The granuloma has shrunk by as much as 50% comparing with photo 1.

Six months post-injection (5 of 6)

Now six months after the steroid injection, not only steroid, but also maturation of the granuloma continues. Compare with photos 1 and 4

One year post-injection (6 of 6)

Now a year after the steroid injection, the granuloma has finished its maturation process and is gone. Only a subtle residual elevation is visible.

Posterior Commissure Synechiae

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Tethered vocal cords (1 of 5)

This man has right vocal cord paralysis and a history decades ago of Teflon injection into the right vocal cord, resulting in posterior commissure synechiae. He is short of breath, partly due to the tissue band and partly because it tethers the vocal cords closer together than they would otherwise need to be as seen in photo 4 after the band is removed. See also photo 5.

Before laser removal (3 of 5)

The thulium laser fiber (F) is touching the synechiae, with laser energy about to be delivered.

Immediately after laser (4 of 5)

This is just after the thulium laser division of the band using topical anesthesia only, with patient sitting in a chair.

One month post-op (5 of 5)

A month later, no residue of the synechiae is seen, and the vocal cords can spring farther apart than in photo 1.

Videos:

Contact Granuloma
In this video, Dr. Bastian provides an introduction to contact granulomas.