Oral Oncology (2005) 41, 666669

http://intl.elsevierhealth.com/journals/oron/

REVIEW

Vocal process granuloma of the larynxrecognition,

differential diagnosis and treatment
Kenneth O. Devaney a, Alessandra Rinaldo b, Alfio Ferlito

b,*

Department of Pathology, Foote Hospital, Jackson, MI, USA

Department of Surgical Sciences, ENT Clinic, University of Udine, Policlinico Universitario,
Piazzale S. Maria della Misericordia, I-33100 Udine, Italy
b

Received 4 November 2004; accepted 15 November 2004

KEYWORDS

Summary The vocal process granuloma is a nonneoplastic lesion that most often
develops in the vicinity of the posterior vocal cords, adjacent to the vocal process.
It may be an ulcerated region of the cord, or it may manifest as a nodular polypoid
lesion. Causative factors include gastroesophageal reflux, intubation trauma, and
vocal abuse. This lesion may be mistaken on clinical or pathologic grounds for carcinoma, although thorough microscopic examination usually permits a correct diagnosis. Despite its name, vocal process granuloma is not a true granulomatous
process in a pathologic sense (inasmuch as it lacks aggregates of mononuclear and
multinucleated histiocytes)rather, it is a reactive/reparative process, in which
an intact or ulcerated squamous epithelium is underlaid by granulation tissue or
fibrosis. Treatment of vocal process granuloma centers around conservative voice
therapy, coupled with treatment of any underlying inciting cause (such as gastroesophageal reflux). While it may recur locally (particularly if the original inciting
cause persists), vocal process granuloma has no premalignant potential.
c 2004 Elsevier Ltd. All rights reserved.

Vocal process
granuloma;
Contact ulcer;
Larynx

Introduction
Patients presenting with hoarseness, dysphagia or
sore throat typically prompt clinicians to consider
a great variety of potential etiologies, ranging from
* Corresponding author. Tel.: +39 0432 559302; fax: +39 0432
559339.
E-mail address: a.ferlito@uniud.it (A. Ferlito).

inflammatory conditions to benign tumors to malignant neoplasms. Amongst the nonneoplastic possibilities are rare entities (including amyloidosis
and sarcoidosis) and particularly common conditions, such as vocal cord nodules and polyps. Somewhere in between these two extremes lies the
vocal process granuloma, an altogether benign entity that may spark consideration of both benign
and malignant lesions during the course of initial

1368-8375/$ - see front matter c 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.oraloncology.2004.11.002

Vocal process granuloma of the larynx

clinical evaluation.13 Synonyms for vocal process
granuloma include contact ulcer, intubation granuloma, vocal granuloma, inflammatory polyp of
the larynx, peptic granuloma of the larynx, vocal
fold granuloma, and pyogenic granuloma of the
larynx.49

667
Perhaps the chief value of this finding may lie in
its utility as a reminder, when present, that a suspected carcinoma of the vocal process region may
in actuality represent a benign process, a vocal
process granuloma.

Microscopic findings
Clinical features
Vocal process granulomas are more often encountered in male than in female patients. While pediatric patients with these lesions have been
recognized,8 this is in the main a condition that affects adults. Presenting signs and symptoms usually
include dysphonia, coupled with other complaints
such as globus symptoms, hoarseness, cough, odynophagia, or sore throat. Patients may report that
these symptoms have been present for periods
ranging from months to years.3,1014
Vocal process granulomas have been associated
with three chief inciting causes: gastroesophageal
reflux, intubation trauma, and vocal abuse. Gastroesophageal reflux patients with vocal process granulomas are usually adult males in the fourth or fifth
decades of life.8 Post-intubation patients with
vocal process granulomas may be of any age or
sex, although the majority of pediatric patients
are post-intubation patients, and adult women
with vocal process granulomas appear more likely
to be post-intubation patients as well. Patients
with a past history of vocal abuse (repetitive throat
clearing or coughing, for example) may be either
male or female.3,68

Physical examination and radiographic

findings
Laryngoscopy typically exposes an image of vocal
process granuloma as either an ulcerated or space
occupying lesionthat is, vocal process granulomas may appear either as a region of epithelial
ulceration (and so expose an underlying erythematous ulcer bed), or may take the form of a nodular
or exophytic mass lesion (often reddish or grey).
These lesions may affect one or both vocal cords.
While the great majority of these lesions are located at the vocal process of the arytenoid,15 they
are occasionally encountered in the middle third or
the anterior portion of the cords.8
CT scanning often reveals osteosclerosis of adjacent arytenoid cartilage,6,16 but the relatively nonspecific nature of this finding may limit its utility.

Vocal process granulomastheir name notwithstandingare not actually granulomatous lesions

on light microscopic examination at all (in that
they lack prominent aggregates of mononuclear
and multinucleated histiocytes of the sort often
associated with sarcoidosis or with mycobacterial
infections). Their name is derived from their gross
appearance, typically manifesting as nodular lesions with a reddish hue. By light microscopy, the
biopsy specimen derived from a vocal process granuloma will be marked either by an intact epithelial
surface, or an ulcerated surface. The adjacent tissues are expanded by granulation tissue and an
attendant population of acute and chronic inflammatory cells.5,17,18 As these lesions age, granulation tissue may be replaced first by fibrosis and
finally by hyperplasia of the superficial squamous
epithelium. Neither squamous dysplasia nor carcinoma in situ are features of the overlying epithelium of a vocal process granuloma.4

Ancillary histologic studies

In general, the light microscopic appearances of
vocal process granulomas will usually suffice to
suggest the diagnosis; as a consequence, ancillary
studies are not often recruited into the pathologic
diagnostic process. In the case of a lesion with a
striking degree of ulceration and a heavy subepithelial inflammatory infiltrate with granulation tissuethe sort of pattern, that is, which may
prompt fears of a subtle pattern of invasive carcinoma obscured by an overlying reactive/reparative
processimmunohistochemical staining for cytokeratin may aid in excluding the possibility of
either an obscured conventional invasive squamous
carcinoma, or a spindle cell carcinoma.

Differential diagnosis
The typical location of the vocal process granulomaalong the posterior aspect of the vocal
cordsis a decidedly uncommon site for squamous

668
carcinomas to arise; nevertheless, clinical concern
with regard to the possibility of a squamous carcinoma (which is often magnified either when the lesion is a bulky, exophytic process, or when it arises
in an atypical location other than the posterior larynx adjacent to the vocal process) explains why
these lesions are often biopsied at the time of
laryngoscopy.
Pathologic differential diagnostic considerations
include vascular lesions (such as hemangioma, Kaposis sarcoma, or angiosarcoma), as well as
inflammatory processes related to infectious
agents.17 As noted above, this process is not actually a granulomatous inflammatory process on
pathologic examination; recognition by light
microscopy of a pattern of true granulomatous
inflammation should prompt the pathologist to
consider other etiologies (such as mycobacterial
or fungal infection, or sarcoidosis).1921

Treatment
The keystone of modern therapy for vocal process
granuloma is conservative voice therapy22 (which
may include vocal rest and speech therapy)extensive surgical excision of the lesion is
not necessary here. Conservative treatment is also
indicated for obstructing vocal cord granuloma.23
Speech therapy is beneficial even if microsurgical
therapy with or without CO2 laser is used. When
possible, treatment of the underlying presumed
inciting factor is important as well (as, for example, instituting antireflux therapy in those patients
whose lesions are related to gastroesophageal reflux disease). To be sure, diagnostic laryngoscopy
is typically undertaken in the course of initial evaluation of these lesions to exclude the possibility of
a more aggressive process; however, incomplete
removal of the lesion at the time of biopsy does
not interfere with its eventual healing.2426 Only
in exceptional cases should it be necessary to resort to more extreme forms of treatment, such as
steroids, botulinum toxin or membranous vocal
fold augmentation.14,26 The use of low dose radiotherapy has also been used with good effect.27

Prognosis
The vocal process granuloma has no recognized
premalignant potential; as a consequence, this is
a head and neck lesion that enjoys a uniformly good
prognosis. Vocal process granulomas may recur
(particularly in patients with continuing vocal over-

K.O. Devaney et al.

use problems),16 but do not have a tendency to
uncontrolled local growththeir maximum dimension rarely exceeds three centimeters.17 Postintubation vocal process granulomas, in particular, do
not usually recur following treatment.26

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