Vocal Granuloma

What is a vocal granuloma?

A vocal granuloma is an inflammatory mass that forms in the back of the larynx (voice box). They form as the body’s response to an area of injury in the back of the larynx.

A granuloma can occur anywhere in the body. Essentially, a granuloma is just swollen tissue. Granulomas grow due to irritation in the body. The body reacts to irritants by creating inflammation (swelling) and by creating a mass around that irritation. When that mass forms, the rest of the body is protected from the source of irritation.

For example, if a stitch is left in the skin for too long, a granuloma may form around the stitch. This prevents other parts of the skin from reacting to the stitch material. The granuloma walls the stitch off from the rest of the body.

Vocal granulomas occur when the lining on the cartilage in the back of the larynx is injured. This cartilage is called the arytenoid cartilage and it is covered by a thin lining, similar to the lining on the inside of your cheek. When the lining is injured, it results in the cartilage being exposed to air, food, and acid reflux. When this happens, the cartilage becomes irritated. Rather than allowing that irritation to spread, the body creates a granuloma around that area of injured lining.

How does the cartilage lining get injured?

The most common ways for the lining to be injured and result in exposed cartilage are:

• Intubation for surgery (breathing tube placed during all general anesthesia)
• Intubation for illness (breathing tube placed during hospitalizations, for example, head injuries, lung infections, etc)
• Forceful voice use, including:
  • singing aggressive styles (i.e., gospel, rock, etc)
  • singing incorrectly (i.e., poor technique, when unwell)
  • singing in poor environments (i.e., poor amplification, poor monitors, loud environment, etc)
  • throat clearing
  • coughing
  • shouting

Once the lining is injured, it is difficult for it to heal. You are probably still doing things that prevent the lining from healing (talking, singing, shouting, etc). When the lining cannot heal, the body tries to cover the cartilage by creating a granuloma.

Imagine what happens when you fall and skin your knee. If you do not touch the area of injury, it will begin to heal and scab over. However, if you keep on picking the scab, the injured area will not heal. Picking the scab is the same thing as continuing to talk after you have injured the vocal lining. The lining cannot heal under these conditions.

vocal granuloma Symptoms

The symptoms of a vocal granuloma vary according to your vocal demands.

If you are a vocational voice user (i.e., someone who uses their voice for their living, such as a singer, actor, voiceover artist, etc), you will possibly notice:

• Chronic hoarseness
• Pitch change in your voice
• Significantly decreased range (no longer hitting higher notes easily)
• Inability to sing quietly
• Inability to hold a pitch steady
• Throat pain
• Voice fatigue

It is rare, if not impossible, to access your full vocal range with a granuloma.

Self-Check

It is not always easy to know if you have a granuloma. Two possible self-checks are

• See if you feel discomfort when you rub your neck around your larynx (voice box). Often pain develops from granulomas due to incorrect voice use.
• After a good warm-up, attempt to glissando to the highest notes you can normally reach. If you are unable to reach them comfortably, without increased effort, you may have a granuloma.

If you are an avocational voice user, you will possibly notice:

• Throat discomfort, pain, or tightness
• Hoarseness in your speaking voice

A granuloma will look like a growth that occurs on one side of the larynx. It occurs in the back of the larynx, at the site of the cartilage.

It may be whitish, yellowish, or occasionally blood-stained. Rarely there are granulomas on both side of the larynx.

On stroboscopy, the cord may not vibrate at all due to the weight of the granuloma on the vocal cord. The granuloma may sit on top of the cord and dampen the vibration. In cases of smaller granulomas, the vibration may be less affected.

How do I know if I have a granuloma?

The only way to know if your symptoms are due to a granuloma is to have your vocal cords examined. This requires the use of videostroboscopy by a laryngologist.

vocal granuloma Complications

There are complications of granulomas, particularly when the diagnosis is made very late. Complications include:

• Painful phonation/voice use
• Need for surgery

How can I avoid having a complication?

Early diagnosis is the key to avoiding these complications. This means coming in for evaluationas soon as you are hoarse.

Truths & Myths

Myth: A granuloma means the end of my career.

Truth: Quite the opposite! When diagnosed early, granulomas are treatable without surgery and can leave no permanent injury.

Myth: Granulomas require surgery.

 Truth: Granulomas rarely, if ever, require surgery.

Myth: Granulomas are not preventable.

Truth: It is true that granulomas are sometimes unavoidable, such as those that are due to intubation (breathing tubes placed during surgery or hospitalization). However, those that are due to voice misuse or overuse are preventable. If good vocal hygiene is used, you should be able to prevent a granuloma from forming. Having an exam before you have a problem can detect problems with vocal hygiene.

Vocal Granuloma Treatment

Treatment is most effective when a granuloma is caught early and diagnosed correctly.

This may seem simple, but without videostroboscopy it is much more difficult.

How do you handle vocal granulomas?

The best treatment is accurate diagnosis. Any singer or voice user who notices a change in their voice should seek immediate attention from a laryngologist. Rarely, a very large granuloma requires surgery to ensure that the airway is not impacted. However, more commonly, medications and vocal hygiene are all that are required to ensure total resolution of a granuloma.

At the Voice Division at Osborne Head and Neck Institute (OHNI), we understand that your voice is your livelihood. We take the utmost care to prevent poor voice outcomes. Your evaluation at OHNI includes:

•  A complete history
•  A complete physical exam of the head and neck
•  Laryngoscopy
•  Videostroboscopy
•  Treatment planning – this usually includes voice therapy with a skilled therapist, trained in the treatment of voice disorders

This comprehensive evaluation results in the best treatment plan for you, that will help prevent you from having future problems.

Can I just see my regular doctor?

Unfortunately, few people are trained to correctly diagnose and treat voice disorders. Only a laryngologist can accurately diagnose and treat you, and help prevent you from having a worse problem.

What should I ask my doctor when I see him/her to ensure I’m getting the right treatment?

You should ask your voice physician the following questions to ensure you are getting the treatment you deserve:

1. Are you board certified in ENT?
2. Are you fellowship-trained in laryngology/professional voice?
3. Do you perform videostroboscopy?
4. Do you perform the examination on your patients?*
5. When surgery is needed, do you perform the surgery yourself or are there other doctors or doctors-in-training involved?*
6. Do you accept insurance? Are your services covered by insurance?

*Often, laryngologists are located in facilities where residents or fellows (doctors-in-training) perform a large portion of the services.

Does insurance pay for a laryngologist visit?

If the laryngologist accepts insurance, your visit is usually covered. Laryngoscopy with stroboscopy is also usually covered. It is best to ask your doctor’s office billers to clarify insurance issues.