David Goldfarb, DO Princeton, New Jersey
Figure 1. Granuloma interfering with phonation when the mass slips subglottically during adduction and causes failure of glottic closure (upper left). The mass can be seen in various positions with relation to the airway and other vocal fold, depending upon the degree of adduction (upper right, and lower figures).
Figure 2. Even in wide abduction, the mass partially obstructs the airway, although the obstruction is not clinically significant. A contact hematoma is visible on the other vocal fold (arrow).
The patient is a 38-year-old female homemaker who developed progressive symptoms of cough, hoarseness and intermittent shortness of breath one month after intubation for emergency surgery . She had no significant medical problems, and her only medication was a multi vitamin. She smoked cigarettes for 10 years, but quit 13 years prior to this evaluation. On examination, the patient had a breathy voice. A large pedunculated mass was attached to the right vocal fold. The mass was attached to both the inferomedial aspect of the right posterior vocal fold and the medial aspect of the right arytenoid. A small hematoma was noted posteriorly on the left vocal fold as well, secondary to constant trauma from the right vocal fold mass. However, the mass interfered intermittently with the vocal fold approximation during phonation (Figure 1) and partially obstructed the glottic airway during inspiration (Figure 2). The arytenoids were mildly erythematous in color. True vocal fold color was other wise normal. The mass was removed by microscopic direct laryngoscopy with CO laser. The histopathology was remarkable, as expected, for granuloma. The patient's symptoms immediately resolved, and she has not had any further problems.
Photography for this series is sponsored by Passy-Muir Inc., manufacturers of the Tracheostoiny and Ventilator Speaking Valves. For further information, please call 1-800-634-5397.
ENT-Ear, Nose & Throat Journal, March 1996