Laryngeal contact granuloma after radiotherapy in patients with nasopharyngeal carcinoma: a case series

Abstract

Background: Laryngeal contact granuloma (LCG) is a benign hypertrophic lesion and phonatory injury after abnormal vocal behavior is regarded as its major etiology. Patients receiving radiation for non-laryngeal head and neck tumors are troubled by persistent voice impairment. The occurrence of LCG after radiotherapy for nasopharyngeal carcinoma (NPC) in our practice has implored us to re-exam their underlying etiology. We hypothesize that a proportion of LCG results from voice change caused by non-laryngeal head and neck cancer radiotherapy and firstly describe a distinct LCG population originated after radiotherapy for NPC with respect to the clinical profile, presentation, prognosis and response to treatment of patients.

Methods: We retrospectively reviewed the laryngoscopic examination and tumor study findings to elucidate the common clinical features of patients who presented with LCG after radiotherapy for NPC. All patients were regularly monitored with telescopic examination until lesions disappeared. Data on age, sex, clinical presentation, telescopic findings, management, latency time of lesion formation, remission time and clinical outcome were reviewed.

Results: The medical review identified 27 cases of LCG secondary to radiotherapy for NPC. All lesions had been diagnosed during routine endoscopy following radiation. The interval between radiation onset and endoscopic diagnosis was 3.77 months (range, 0.67-11 months). 20 cases were resolved through simple observation, 4 cases were resolved with the administration of proton pump inhibitors (PPIs), and 3 cases with a poor response to PPI therapy required subsequent surgical resection. The mean remission time in the observation and PPI groups was 4.42 months (range, 0.73-18.9 months) and 5.78 months (range, 2.17-14.63 months), respectively. All patients recovered completely and none experienced recurrence during a mean follow-up of 32.44 months (range, 5.6-71.67 months).

Conclusions: Iatrogenic granulomas of vocal process are presenting after radiation for non-laryngeal head and neck cancers. In contrast with spontaneous granulomas, these granulomas can be cured at high remission rates and low recurrence trend without specific intervention. Thus, simple observation may be sufficient for radiation-induced LCG.

Keywords: Laryngeal contact granuloma (LCG); nasopharyngeal carcinoma (NPC); non-laryngeal head and neck cancer; radiotherapy (RT).

Figure 1

Left vocal fold lesion after RT for NPC (T4N2M0). (A) A 43 year old man was diagnosed with NPC (T4N2M0) and (E) meanwhile no evidence of LCG was identified. (F) Approximately one month after radiotherapy started (B) the tumor vanished while the left vocal process was observed with a grade III granuloma. (G) A year later the lesion only slightly regressed. (H) During a 2 year follow up the lesion disappeared and showed no recurrence. (C,D) This patient had no sign of tumor recurrence around the nasopharynx or skull base. RT, radiotherapy; NPC, nasopharyngeal carcinoma.

Figure 2

Bilateral lesions after RT for NPC (T3N2M0). (A) A 39- year- old man was diagnosed with NPC (T3N2MO) and (E) LCG was not found initially. Four months later, (B) nasopharyngeal tumor vanished postradiotherapy and (F) LCGs were present with gradeIIulcerative lesions bilaterally. (G) After three months the left lesion achieved completely remission and the right side largely regressed. (H) No relapse of LCG was recorded In the 6-month followup. (C)(D) This patient had no evidence of tumor recurrence around the nasopharynx or skull base. RT, radiotherapy; NPC, nasopharyngeal carcinoma.

Figure 3

Morphologic characteristics of LCG with different size. (A) Unilateral keratotiic lesion of grade I. (B) Unilateral ulcerative lesion of grade II. (C) Unilateral exophytic lesion of grade III. (D) Bilateral bilobular lesions. LCG, laryngeal contact granuloma.