GERD-associated laryngeal granuloma: a series of clinical observations. Case report

Abstract

Laryngeal granuloma is a benign neoplasm located on the vocal processes of the arytenoid cartilage. The causes of development may be prolonged or traumatic intubation (23%), gastroesophageal reflux disease leading to chronic cough (30%), excessive vocal load (33%); respectively, post-intubation, contact and idiopathic granulomas are distinguished. In laryngopharyngeal reflux, an extraesophageal manifestation of gastroesophageal reflux disease, morphological changes in the mucous membrane of the larynx and pharynx occur as a result of direct exposure to acidic stomach contents, pepsin, bile and pancreatic enzymes that cause the development of contact laryngeal granuloma. Diagnosis of laryngopharyngeal reflux includes analysis of the patient's life history, registration of complaints using questionnaires, assessment of the clinical and functional state of the larynx using visual analog scales of reflux signs, the use of instrumental methods and laboratory tests. The latter determine the acidity of gastric juice, bile acids, pepsin, as well as the presence of Helicobacter pylori. Instrumental methods include esophagogastroduodenoscopy, videolaryngostroboscopy, esophageal manometry and 24-hour pH impedancometry – the most accurate method for diagnosing reflux in the esophagus, regardless of the pH of the bolus. During videolaryngostroboscopy in patients with the laryngopharyngeal reflux, laryngeal lesion is often detected in the form of swelling, hyperplasia of the mucous membrane of the intercostal fold and posterior vocal folds. The treatment of patients with laryngeal contact granulomas is based on a combination of antireflux therapy and phonopedia. Surgical intervention is necessary only in the case of large granuloma sizes for morphological verification and restoration of glottis patency. Complex rational therapy of patients with laryngopharyngeal reflux, including the use of proton pump inhibitors, prokinetics and antacids, can increase the effectiveness of surgical treatment of patients with laryngeal granuloma and reduce the risk of recurrence. The own clinical observations presented in the article emphasize the importance of an interdisciplinary approach of laryngologists and gastroenterologists to the diagnosis and treatment of patients with reflux-associated laryngeal granulomas, which makes it possible to minimize and in some cases avoid surgery.

Keywords

• laryngopharyngeal reflux
• gastroesophageal disease
• benign diseases of the larynx
• pachyderma
• granuloma
• videolaryngostroboscopy
• larynx