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The existence of a wide range of treatments for recurrent laryngeal granulomas (repeat surgery, high-dose proton pump inhibitor (PPIs), surgery with botulinum toxin injection, botulinum toxin injection alone, etc) is a testament to the refractory nature of this condition, with no one treatment demonstrating an ideal therapeutic side-effect profile. In this paper, the authors describe their experience in managing 299 cases of recurrent laryngeal granulomas over a six-year period. Of these, 33 cases were treated with PPI alone, whilst 266 received both a PPI and injection(s) of triamcinolone into the granuloma under local anaesthetic via a thyrohyoid approach. Injections were repeated if the granuloma was still present at follow-up flexible laryngoscopic examination. It is reported that in the patients who received combination treatment, 81.2% (216/266) achieved cure (complete resolution of the granuloma with no recurrence over a median follow-up time of 16 months) compared to 57.6% (19/33) treated with PPI alone (p < 0.05). The recurrence rate for combined treatment and PPI monotherapy was 3% and 12.1% respectively. Time to cure was also shorter for combined treatment (4.3 vs. 6.8 months, p < 0.001). There are several limitations to this study, the primary ones being its retrospective nature, the significantly mismatched numbers of patients in each intervention group and the unclear selection criteria for treatment modalities. Nevertheless, the beneficial effect of inhaled steroid treatment for laryngeal granulomas has previously been reported and, as such, it is plausible that a direct steroid injection will also provide benefit without the regional and systemic side-effects of inhaled steroids. Ideally, the data from this study can be corroborated by a well-designed prospective randomised control trial (RCT) that also quantifies the number of steroid injections required to achieve cure but, until then, this paper does provide further evidence to support the use of direct steroid injections in the treatment of laryngeal granulomas.

Comparison of PPI and combined treatment in the treatment of recurrent laryngeal contact granuloma.
Nie Q, Li J, Zou S, Zhang R.
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Christopher Burgess

Musgrove Park Hospital, Taunton, UK.

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