Granulation Tissue

Granulation tissue is tissue that develops as an exuberant “over-healing” response to irritation or injury. This irritation or injury could be due to an endotracheal tube, or a superficial cordectomy wound from surgery, or a number of other causes. Granulation tissue that forms on the posterior vocal cord is called a contact granuloma.


Subglottic granulation and curving airstream: Series of 4 photos

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Proud flesh within cricoid ring

Intubation injury (1 of 4)

After a 9-day intubation for serious illness, the patient has difficulty breathing due to this “proud flesh” response to injury within the cricoid ring, posteriorly. Breathing has improved in the past week, leading to a decision to await further maturation, rather than proceeding to microlaryngoscopic removal.
lobules of granulation tissue

Lobules (2 of 4)

Close-up view of the lobules of granulation tissue. Air can easily pass around the obstruction as indicated by the arrows.
subglottic scar band

2 months later (3 of 4)

As predicted, breathing continued to improve to the point of seeming normal to the patient, and 2 months later, the granulation tissue has matured and detached, leaving behind a subglottic scar band (parallel lines).
anterior border of the scar band

Scar band (4 of 4)

Here is a close-up of the scar band. A solid line denotes the anterior border of the scar band for reference in all 4 photos, but compare especially to photo 2.

Sometimes you DO remove granulation to avoid tracheotomy: Series of 8 photos

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scarring of the posterior commissure

Granulation (1 of 8)

Prior to this first visit, this person suffered extensive burns, was intubated for 10 days, and then underwent tracheotomy, and then was decannulated (tracheotomy removed). She has scarring of the posterior commissure outlined by the dotted line. The granulation extends well down into the subglottis. She is uncomfortable with a marginal airway and noisy breathing. Laser and microdebrider are planned to try to avoid having to reinsert the tracheotomy.
granulation and scarred area

Closer view (2 of 8)

Tip of the iceberg view of granulation and scarred area.
granulation has finally matured

Post microlaryngoscopies (3 of 8)

After a series of microlaryngoscopies purely to improve airway and avoid tracheotomy, the granulation has finally matured. Airway is no longer marginal, but is still very limited for significant activity.
area of posterior scarring

Scarring (4 of 8)

At close range, the area of posterior scarring is again indicated by dotted line; the dark area of the actual airway is narrow and slit-like.
widened space posteriorly

Post posterior commissuroplasty (5 of 8)

A month after posterior commissuroplasty, breathing is improved due to the widened space posteriorly. Compare the dark area for breathing with photo 3.
vocal cords Six months after posterior commissuroplasty

Breathing improved (6 of 8)

Six months after posterior commissuroplasty, breathing remains much improved. Compare dark airway contour again with photo 3 above.
closer view of the airway

Closer view (7 of 8)

A closer view of the airway, which is much wider posteriorly than preoperatively (photo 4).
Phonatory view

Phonatory view (8 of 8)

When patient makes voice, there is a persistent space posteriorly, where the airway was surgically widened, but again, this has not significantly affected the voice.

Laser surgery for Bilateral Vocal Cord Cancer

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squamous cell carcinoma

Squamous cell carcinoma (1 of 6)

This man developed hoarseness across a few months. Biopsy elsewhere revealed squamous cell carcinoma, seen here on both vocal cords. Based upon a friend’s experience, he rejected radiotherapy, opting for laser resection, knowing it could be very hard on voice.
Tumor on the vocal cords

Tumor on the vocal cords (2 of 6)

At closer range and under narrow band (blue-green) light to accentuate the vascular abnormalities associated with this tumor.
superficial laser cordectomy

Granuloma delays voice recovery (3 of 6)

Six weeks after superficial laser cordectomy, the larynx is almost healed with the exception of a small granuloma, left vocal cord (right of photo). When healing includes granulation, voice recovery is delayed as the granuloma resolves.
granuloma prevents vibratory closure

Closer view of granuloma (4 of 6)

He has hoarse but functional voice, but under strobe light, the granuloma prevents vibratory closure. Note the medial-to-lateral capillary reorientation so typical after laser cordectomy.
Granuloma on vocal cord

Granuloma is smaller (5 of 6)

Now 3 ½ months from surgery, voice has improved further and he considers it “75%” of original...One can see that the granuloma is smaller.
ranuloma no longer prevents vibratory closure

Granuloma doesn't impede voice (6 of 6)

Note that the granuloma no longer prevents vibratory closure and this explains further improvement of voice. Compare with photo 4.