State-of-the-Art Techniques Are Tempting, but May Not Improve Care

As for performing cup biopsies of the vocal fold, he cautioned that many younger physicians have no experience in doing this, and that technique is vital or damage is done.

Another way to manage the patient is to watch, said Dr. Sulica. This is a contralateral lesion, more than five years out after the second. This is a new primary. You cured the first primary…But you’re being told this is microinvasive. I was surprised that not more people felt they could watch this reliable patient, who gives a good stroboscopic exam. If it comes back, I don’t think you need a new biopsy to treat him with radiation, he said.

With the recurrence, and taking into account the patient’s comorbidities, Dr. Woo considered radiation because the patient was a poor surgical risk and wasn’t likely to live long enough to see some of the complications from radiation therapy. Also, Dr. Woo didn’t want to see the condition progress into something more severe.

Reflux Testing for Granulomas

The third case was of a 58-year-old trial lawyer with a suspected contact granuloma of the larynx. Biopsy was not recommended. Management of this sort of case varies widely, with treatments ranging from oral steroids to proton pump inhibitors (PPI) to speech therapy. The patient was put on a double-dose of PPIs for six months and speech therapy.

Even in the presence of technology, the most important thing to do is take a good history and talk to the surgeon.

After four months, the patient had minimal relief. Dr. Woo reported that he excised the granuloma and injected steroids.

Dr. Sataloff suggested making sure any reflux was under control because studies show that reflux can cause granuloma. However, he was critical of the methodology behind some of the 24-hour monitoring studies in the medical literature.

Most of the 24 hour monitors are normed to pH 4, and there is about 10% or so of pepsin activity up to pH 5. I personally use pH impedance studies for everything now, he said. With some patients, 24-hour monitor study normed to pH 4 might show little or no acid, but if it is renormed to pH 5 more episodes appear, he said.

However, reflux is common yet this lesion is rare, said Dr. Shapshay. It’s sometimes reasonable to give [patients] steroids for several weeks, and that granulation tissue will disappear, he said. Over time, most granulomas resolve.