Arytenoid granulomas are often a sequelae of laryngopharyngeal reflux (LPR). Unless there is suspicion of malignancy, they require a very balanced approach between conservative management and surgical intervention. The authors present a series of 62 patients with whom the primary approach was esomeprazole 40mg twice a day and voice therapy for three months. Of these, two thirds responded with complete remission of symptoms and initial endoscopy findings. Twenty-eight out of 62 patients underwent surgery. In 14 of these, surgery was primarily intended for suspicion of malignancy, and in the other 14, laser surgery was undertaken because of failure of conservative management. Eighty-two percent of these had complete resolution of granuloma. Local injection of Botox was used for failed surgical cases. The histopathology in the 14 patients undergoing primary surgical treatment showed squamous cell carcinoma in two and moderate and severe dysplasia in another two. The commonest histological diagnosis was inflammatory granuloma (57%). Interestingly enough, three out of 28 biopsies revealed tuberculosis. Pleomorphic adenoma and amyloidosis were other unusual findings in two patients. The publication presents a good success rate with PPI and voice therapy and also recommends the latter after laser surgery. However, where suspicion of malignancy arises, surgical treatment including biopsy is advised.