MDL - Vocal Fold Granuloma
Considerations
For Dr. Jiang and Dr. Durr
See Chapter 19 of the book Operative Techniques in Laryngology (2008) by Rosen and Simpson
Anatomy
Arytenoid
Vocal process
Indications
Airway obstruction
Rule out malignancy
Rule out infection
Persistence despite medical therapy
2013: Recurrent Contact Granuloma Experience With Excision and Botulinum Toxin Injection
2014: Vocal process granulomas: a systematic review of treatment
Preparation
For the basic preparation, see the Micro-Direct Laryngoscopy - basic page
Special equipment
May need the Pilling posterior commissure laryngoscope
Ask the anesthesiologist
"Small" ETT - size 5
Procedure
Think atraumatic
Think exposure
Position the ETT anterior to the laryngoscope, either by
using the Pilling posterior commissure laryngoscope - or -
angling the ETT so that it enters the glottis from the opposite side as the laryngoscope
Goal: View posterior to the ipsilateral mid-membranous VF and the entire arytenoid / posterior glottis
Suspend
Inspect and palpate
Identify the stalk - a curved alligator (curved away from the side of the lesion) can be helpful
Remove
Hold the lesion at its stalk with the curved alligator
Retract toward the midline
Transect the stalk with the curved microscissors
Hemostasis
topical 1:10,000 Epinephrine soaked pledgets
Re-examine
Remove any residual tissue using 1 mm cup forceps
Optional
Vocal fold augmentation
Vocal fold Botox
Sample operative report
Post-op
Voice rest for 1-2 weeks
For Dr. Durr, use the the University of Texas Voice Rest protocol here
See the smartphrase by J Gilde: JEGPIVOICERESTPO
PPI and LPR lifestyle measures
Complications
Recurrence
Arytenoid cartilage injury
Pearls & Pitfalls
High-Yield
Pathophysiology
VF granulomas result from perichondritis of the arytenoid (intubation, LPR, voice abuse - underlying glottal insufficiency)