Granulomas are wound healing lesions. They occur as a result of trauma which denudes the mucosa and exposes the underlying tissue to the bacteria of the throat. They typically start off life as an ulceration and are associated with pain frequently. It is the type of pain that you might experience when you bite your tongue or cheek, so it has a sharp quality. The granuloma is a collection of capillaries which are hypertrophic.
I was able to attend the 9th Congress of the European Laryngologic Society held in Helsinki, Finland June 13-16, 2012. Meeting Organizers Teemu Kinarai and Heikki Rihkanen. It was an excellent Congress with a great many new ideas. Helsinki, Finland was completely blue and sunny for the three nearly 24 hour sunlit days of the conference. Some of the sessions that stood out in my mind:
Approximately 70-year-old male who has both smoked and consumed alcohol in the past. He also had a cancer removed from the floor of mouth one year ago. He reported a right-sided sore throat and intermittent referred otalgia to his right ear. This exam highlights how using the "trumpet maneuver", cancers of the piriform sinus or lower fairings can be visualized. The patient seals their lips and pretends like they are blowing up a balloon. This back pressure opens up the throat both behind and lateral to the larynx or voice box.
When viewing the larynx with a rigid endoscope, my tendency has always been to place the camera on the endoscope such that the vocal cords are viewed in a vertical position. However, what matters for resolution is the number of pixels that the pathology fills up on the camera. Since voice disorders are always related to the vibrating edge of the vocal cords, the high definition format, 1080i uses up 1920 x 1080 pixels and placing the edge of the vocal cords along the axis of the 1080 pixels wastes much of the viewing frame.
This gentleman had a squamous cell carcinoma or cancer of the right vocal cord. He had only smoked 2 cigarettes per year, so it is unlikely the tobacco had much to do with his cancer. As bad as this looks, it was possible to appeal this cancer off the vocal cord. It had not grown into the vocal cord. After removal, the right vocal cord was very stiff, but his voice returned to normal since the left vocal cord could vibrate normally. In the bottom photo, taken over one year after surgery, his right vocal cord has a fairly normal structure.
So you think you would like to smoke cigarettes? Here is what smoking cigarettes for 30 years did to one person's larynx. See if you can actually see the vocal cords. This is what squamous cell carcinoma looks like when it grows on the surface of the vocal cords. The large pink area on the left is the left false vocal cord. It likely has tumor given its irregular surface appearance. The white rough area in the middle of the photo is the left vocal cord which is almost completely replaced by cancer. The right and left vocal cords have almost grown together with the cancer.
I am having the opportunity to compare images using the Pentax standard definition endoscope VNL-1170K and the high-definition VNL-1590STi. This patient has amyloid depositions in the vocal cords. They cause a stiffening of the vocal cord and allow air to leak out.
A report on the Sociedad Venezuelana de Otorrinolaringologia - 2012 Meeting
Elizabeth is in her 20s and began singing about 3 years ago. About 1 year ago, she noted some roughness in her singing voice. She loves to talk and rates herself a 7/7 on the talkativeness scale and a 7/7 on the loudness scale. Here are her vocal cords when I met her. On the left with the vocal cords open (abduction), there are fairly large white calluses in the center of each vocal cord with the right one being slightly larger. The vocal impairment they create is visible on the right.
James was age 27 when he first came to me for impairment of his singing voice. His singing became more effortful over 3 to 4 years. There was roughness in his upper vocal range. He recently switched from singing baritone, moving to a tenor. He has a very faint swelling on the right mid-vocal cord. ************************************ 2 years later: