What is the management approach for an excrescence (abnormal growth) on the vocal process of the arytenoid?

Management of Excrescence on Vocal Process of Arytenoid

For an excrescence on the vocal process of the arytenoid, initial management should consist of anti-reflux therapy with proton pump inhibitors (PPIs) combined with voice therapy, as vocal process granulomas frequently resolve or regress with this conservative approach. 1

Initial Diagnostic Evaluation

Laryngoscopy is essential to characterize the lesion and rule out malignancy. 1 Key features to assess include:

• Vascularity, ulceration, or exophytic growth - these characteristics raise suspicion for malignancy and require prompt biopsy 1
• Superficial white lesions on mobile vocal folds - may warrant a trial of conservative therapy before biopsy 1
• Associated findings such as erythema of the interarytenoid mucosa, posterior commissure changes, or vocal fold abnormalities that suggest reflux-related etiology 1

Conservative Management Algorithm

First-Line Treatment: Anti-Reflux Therapy + Voice Therapy

Vocal process granulomas have been shown to resolve or regress with anti-reflux medication with or without voice therapy in observational studies. 1 This approach should be attempted before surgical intervention.

PPI therapy specifics:

• Treatment duration of 4 months has shown improvement in laryngeal findings including abnormalities of the interarytenoid mucosa and true vocal folds 1
• Increased pharyngeal acid reflux events are more common in patients with vocal process granulomas compared to controls 1

Voice therapy should be advocated as it is effective for managing hoarseness and laryngeal lesions, though it remains underutilized. 1

Important Caveats About Conservative Management

Limitations of laryngoscopic findings for predicting PPI response:

• Inter-rater reliability for findings of edema and erythema of the vocal folds and arytenoids is problematic 1
• Abnormal findings like the interarytenoid bar can be present in normal individuals 1
• The presence of specific findings depends on the examination method (rigid vs flexible laryngoscopy) 1

Surgical Management

Surgery should be advocated when:

1. Malignancy is suspected - requires surgical biopsy with histopathologic evaluation 1
2. Conservative management fails after an adequate trial (typically 4 months of PPI therapy) 1
3. The lesion causes significant glottic insufficiency affecting voice or airway 1

Surgical Options

Endoscopic excision is the preferred approach for benign vocal process lesions:

• Transoral laryngeal microsurgery (TLM) offers lower morbidity than open surgery 1
• Functional results are optimal when TLM is used as a single modality without need for postoperative radiation 1
• Voice quality after TLM varies with tumor extent; results are poorer for lesions involving the arytenoid 1

Important surgical consideration: Better healing and reduced polyp recurrence after vocal fold surgery occurs in patients taking PPIs compared to those not on PPIs. 1 This suggests continuing anti-reflux therapy perioperatively.

Post-Procedure Monitoring

After any laryngeal procedure or intubation, patients should be monitored closely for signs of respiratory compromise for 6-24 hours depending on the cause and severity. 1, 2

Specific complications to monitor:

• Prolonged intubation, coughing, or repeated endotracheal tube placements can cause formation of obstructive arytenoid granulation tissue 1
• Arytenoid subluxation or dislocation can occur after difficult intubation 3, 4
• Flexible fiber-optic examination of the larynx before extubation is often prudent in high-risk patients 1

What NOT to Do

Do not routinely prescribe oral corticosteroids for laryngeal excrescences or hoarseness, as randomized trials show adverse events without demonstrated clinical benefit. 1 The preponderance of evidence favors harm over benefit for steroid use in this context.