Contact Ulcer

Overview:

Contact ulcers are raw sores, pale or red in color, located on the posterior third of the vocal fold. Contact ulcers can exist on one vocal fold (unilaterally) or both (bilaterally). They develop on the posterior third of the vocal fold because this is where your arytenoid cartilages--the elastic cartilages the vocal folds attach to--are located. (Note: the area of the vocal fold at which the aretynoid cartilages are located are known as the vocal processes.) The sores are located on the mucous membrane covering covering these cartilages. Specifically, there are two subtypes of contact ulcers: specific granulomas and nonspecific granulomas. Specific granulomas are more rare and are caused by tuberculosis and syphilis. Nonspecific granulomas, which are benign, are more common.

Cause:

Vocal Abuse:

People who use their voices excessively, such as teachers, singers, lawyers, preachers, and sales representatives may develop contact ulcers as a result of vocal abuse. Vocal abuse occurs when increased pressure is placed on the vocal folds for sustained periods of time. It also includes voice production patterns such as glottal fry or having hard glottal attacks. When you speak, your two vocal folds abduct and adduct many times. When you are abusing your voice, the thin layer of mucous covering the arytenoid cartilage of the one vocal fold crashes against the opposite vocal fold and the mucosa breaks down. This causes the raw sore known as a contact ulcer.

For information of the treatment of contact ulcers caused by vocal abuse, see the Treatment section.

Gastroesophageal Reflux Disease:

Stomach acid flowing back up into the larynx can also cause contact ulcers as the acid breaks down the mucous membrane covering the arytenoid cartilages of the vocal folds. If your doctor suspects that gastroesophageal reflux disease may be causing your contact ulcers, there are two tests which he/she may utilized to test for the presence of stomach acid: a double-pH probe and pharyngeal pH probe.

For information of the treatment of contact ulcers caused by gastroesophageal reflux disease, see the Treatment section.

Trauma:

Objects such as an endotracheal tube may cause an injury which, in turn, can lead to the development of a contact ulcer.

For information of the treatment of contact ulcers caused by trauma, see the Treatment section.

Other Factors:

Contributing Factors:

• Smoking
• Allergy
• Infections
• Postnasal drop
• Chronic throat clearing

Psychosocial Traits:

• Aggressive personality
• Introversion
• Depression
• Emotional tension
• Cancerophobia 

Dietary Factors:

Some dietary factors can affect the mucous membrane and lead to contact ulcers.

• Caffeine
• Coffee
• Alcohol
• Peppermint
• Spicy foods
• Tomato products
• High-fat diets
• Poor water intake
• Use of tobacco products

Idiopathic:

Occasionally, a contact ulcer develops in a patient for whom none of these factors are apparent or present.

It should be noted that these factors are meant to be informative, and a direct causal relationship in the formation of contact ulcers has not been established.

Symptoms:

• Chronic or acute hoarseness of the voice which can very in degree/severity
• Vocal fatigue
• Mild throat pain when swallowing, coughing, or speaking, especially during pressed phonation
• Cough
• Throat clearing
• Airway obstruction due to the ulcer blocking the space which is normally present between open vocal folds
• Bleeding (usually minor)
• Vocal fold fixation

Diagnosis:

Flexible Nasopharyngoscopy:

A flexible nasopharyngoscopy is a flexible scope allows for a visual of your vocal folds to look for evidence of laryngeal hyperfunction, muscular tension, reflux disease, and the presence of the contact ulcers on the vocal folds. This procedure allows the dynamic activity of the larynx to be evaluated without any distortions that come from opening the mouth and moving the tongue anteriorly, as is done in traditional mirror or rigid telescopic examinations. 

There are two types of flexible scopes. The traditional process does has some disadvantages:

• Reduced detail compared to the mirror or rigid telescopic examinations
• A red bias, or tendency to see the tissue as more red than it really is due to the scope's color scale
• There is a fish-eye distortion of structures 

The newer, chip-end flexible scopes do not have these issues. However they are more expensive and require additional equipment. Therefore, they may not be used by your physician.

Videostrobolaryngoscopy:

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view. 

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

Objective Voice Measurements:

Using objective measurements of the voice is a non-invasive way to measure progress, assess treatment results, and confirm perceived changes by analyzing data regarding pitch, volume, voice quality, and other factors. This could be used as a supplemental procedure to help the treating specialists to adapt a whole-picture view of the patient's current status and any changes that have occurred throughout treatment.

Speech Therapy Evaluation:

An evaluation by a speech language pathologist provides a thorough assessment of the behaviors of the patient that are contributing to their vocal miss-use and the formation and development of the contact ulcer. These evaluations typically examine whether the following are present: poor breath support, hard glottal attack, improper pitch placement, etc. Recommendations for treatment and strategies to correct this behaviors are given. 

Treatment:

Medical:

Cough Prevention and Treatment:

If the cough is due to a recent illness or instrumentation, a cough suppressant such as a narcotic may prescribed. If the cough is chronic, or the patient experiences chronic throat clearing, the following may be used to manage problem: improved hydration, reflux treatment, topical anesthetics, asthma or allergy treatments, and others. 

Antireflux Treatment:

The following treatments may be prescribed to treat reflux diseases: proton pump inhibitors, lansoprazole. rabeprazole, or ranitidine if proton pump inhibitors are not an option.

Lifestyle Modifications:

Lifestyle modifications are crucial and are necessary for every patient, even those who have been prescribed remedies. The following instructions are typically given to patients with contact ulcers:

• Avoid acidic foods that can cause reflux (see Dietary Factors for more information)
• Do not wear tight clothing
• Avoid eating 2-3 hours prior to sleeping
• Sleep with your head elevated

Speech Therapy:

Speech therapy is essential for patients who have developed their contact ulcer from vocal miss-use, trauma, or reflux. In speech therapy, patients will work with a skilled professional to improve their breath support, reduce their hard glottal attack, and eliminate other habits such as excessive throat clearing or vocal straining which cam cause and contribute to contact ulcers. 

Botulinum Toxin Type A:

Botulinum toxin type A is a toxin that is injected into the thyroidarytenoid muscle on the side of the larynx of the contact ulcer. This toxin acts by chemically paralyzing the muscle for a period of 3 months, which reduces the force of the glottal attack and the amount of impact between the two vocal folds while speaking or coughing. It is used for contact ulcers which are non-responsive to other forms of treatment, however speech therapy is conducted during the same time period as when this treatment is being administered so that this new soft glottal attack can be carried over after the injection wears off. 

Surgical:

Surgical treatment to remove the contact ulcer is usually held as a last-resort for cases in which other treatments fail to work, when cancer is suspected, when the lesion is a fibroepithelial polyp, or when the airway and breathing is compromised. It is reserved for these cases as these surgeries have a high recurrence rate of 37-50% and can cause the ulcer to migrate in some cases. Two types of surgical procedures are currently used for the treatment of contact ulcers: 1.) excision to remove the ulcer, and 2.) the use of a laser to stop the feeding vessels from reaching the ulcer, therefore stunting its growth. The use of the flash lamp pulse dye laser is still investigational and the long-term efficacy is unknown at this time. 

Pre-Operation:

Prior to surgery, the patient should follow the following advice accordingly to increase the chances of healing and decrease the risk of recurrence:

• Attend speech therapy to reduce and eliminate vocally-abusive behaviors
• Modify diet and behavior to reduce reflux
• Utilize medical treatments for the management of reflux
• Follow the vocal rest guidelines after surgery

Intra-Operation:

The approach that your surgeon will take during your procedure may include the following: removing part of the ulcer in order to shrink the base, removing the entire ulcer with a cold-knife excision, or a low-watt laser. It is best to discuss the procedure with your physician and surgeon.

Post-Operation:

After surgery, the following guidelines must be followed to ensure proper healing:

• Vocal rest for two weeks (no audible sounds, whispers, or throat clearing)
• Continue anti-reflux treatment
• Continue dietary and behavioral modifications
• Perform a video laryngeal stroboscopy at 2-, 4-, and 8-weeks post-operation to monitor the healing process and adjust the treatment plan as necessary

Follow-Up:

The patient must receive follow-up care on a regular basis to monitor recurrence and the development of secondary lesions on the vocal folds.

Complications:

• Recurrence
• Migration following surgery
• Airway obstruction
• Minor bleeding
• Vocal fold fixation
• Formation of a scar bridge, leading to vocal fold immobility

Outcome/Prognosis:

• 80-100% of patients with contact ulcers respond to medical and/or surgical management
• 80-90% of patients whose major risk factor for contact ulcers is vocal abuse respond to speech therapy and medical management
• 70-80% of patients whose major risk factor for contact ulcers is reflux respond to medical management
• 100% success rate for the use of botulinum toxin type A (note: the numbers in these studies have been small)

References:

Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. Aug 2009;13(8):1422-9. 

Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52.

Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas. Laryngoscope. Feb 1999;109(2 Pt 1):301-6.

Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3.

http://www.merckmanuals.com/home/ear_nose_and_throat_disorders/throat_disorders/vocal_cord_contact_ulcers.html

http://emedicine.medscape.com/article/865924-overview