Clinical studies of contact granuloma and posterior laryngitis with special regard to esophagopharyngeal reflux

Detta är en avhandling från Stockholm : Karolinska Institutet, Department of Clinical Sciences

Sammanfattning: This investigation had two main goals. The first goal was to evaluate the clinical symptoms and signs of contact granuloma patients and to study the short-and long-term treatment outcomes. The second goal was to determine the occurrence of esophagopharyngeal reflux (EPR) in patients with contact granuloma and patients with posterior laryngitis, as well as in healthy controls, and to study the association of symptoms, laryngeal findings, and esophagopharyngeal reflux. In a retrospective study, the hospital records of 123 contact granuloma patients were studied. The predominant symptoms were vocal discomfort, the need for excessive throat clearing, and hoarseness. The recurrence frequency after surgery was 92%. Six months after voice therapy there was no significant difference in healing frequency between the operated patients with recurrence and the unoperated patients. The operated patients had a mean recovery time of 17 months, compared to 8 months for the unoperated group. Perceptual and acoustic voice characteristics as well as the laryngeal findings were analyzed for 19 male contact granuloma patients before and after voice therapy and at a follow-up about 9 years later. Pre-therapy, the most salient voice characteristics were low pitch, a high degree of vocal fry, and hyperfunction. About half of these granuloma patients had a mean F0 lower than expected for their age. Immediately after therapy the healed patients had a decrease in hyperfunction, vocal fry and monotony, but these differences were not statistically significant. With regard to acoustic analyses, no significant differences were found in mean fundamental frequency (F0) or perturbation before and after therapy. In a follow-up study, 59 contact granuloma patients were interviewed and reexamined. History revealed a recurrence frequency of 20% after primary treatment, and the recurrence frequency during the first 5 years after treatment was 12%. Of the investigated patients, 17% displayed a contact granuloma at follow-up and 47% had other mucosal lesions of the posterior glottis. Ambulatory 24-hour esophagopharyngeal pH monitoring was used to measure reflux parameters in the pharynx and distal esophagus. One study included 26 granuloma patients; the other study included 26 patients with posterior laryngitis and 17 with a normal larynx. Nineteen healthy subjects were used as a control group, EPR was significantly more prevalent in granuloma patients and in patients with posterior laryngitis than in the healthy controls. Moreover, there was no statistically significant difference in the distal esophageal reflux parameters between the groups, except in the percentage of esophageal reflux episodes that reached the pharynx, which was higher in both these patient groups than in the healthy controls, EPR caused no specific subjective symptoms, and the laryngeal findings in these patients could vary from normal mucosa to thickening, edema, and erythema of the posterior wall of the glottis. Conclusions: Contact granuloma should be regarded as one manifestation of posterior laryngitis, and should not be treated by surgery. Voice therapy is indicated for patients with a hyperfunctional voice quality as well as for patients with symptoms associated with voice use. The prevalence of contact granuloma may be higher than previously estimated. EPR may be a contributory factor to contact granuloma as well as to posterior laryngitis, but a certain degree of EPR appears to be a normal phenomenon. Because subjects with EPR may also display a normal laryngeal mucosa, the mere entry of reflux into pharynx is not always enough to cause laryngeal lesions. EPR does not yield specific laryngeal symptoms, which makes it unreliable to base the diagnosis on symptoms alone. Since abnormal esophageal reflux parameters are not mandatory for these patients, and pathological distal esophageal reflux does not necessarily lead to pharyngeal reflux, double probe pH monitoring from pharynx and distal esophagus is necessary for correct diagnosis of EPR.

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