Acta Oto-Laryngologica.

2015; 135: 277–282

ORIGINAL ARTICLE

Analysis of therapeutic methods for treating vocal process granulomas

LIJING MA, YANG XIAO, JINGYING YE, QINGWEN YANG & JUN WANG

Key Laboratory of Otolaryngology Head and Neck Surgery (Ministry of Education of China), Department of
Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China

Abstract
Conclusion: The combination of laryngeal microsurgery and local injections of botulinum toxin type A (BTA) can increase the
cure rate of patients with vocal process granulomas (VPGs). Objective: To analyze the therapeutic effects of conservative
treatments, microsurgical resection with suturing and microsurgery in combination with local injections of BTA for the
treatment of VPGs. Methods: A retrospective analysis of 168 cases of VPG was performed. All of the patients initially received a
conservative treatment. Some of the patients who did not respond to the conservative treatments were treated using
microsurgical resection and microsuturing using an 8-0 absorbable filament. Other patients additionally received a four-
point injection of BTA into the thyroarytenoid muscle and the arytenoid muscle on the operated side. Results: The lesions of
41.3% (71/168) of the patients who were given the conservative treatments (including acid suppression, vocal rest, and voice
therapy) disappeared, and the lesions of 10.7% (18/168) of the patients were reduced. The conservative treatments were
unsuccessful for 47% (79/168) of the patients. The cure rate was 78.4% (29/37) for the patients who were treated by
microscope resection using a CO2 laser and microsuturing of the surrounding mucosa. Of the eight patients who experienced a
recurrence, five of them had lesions that disappeared after 3 months of conservative treatment, whereas the other three patients
recovered after a second operation. The cure rate of the 42 patients who were treated using microsurgery combined with local
injections of BTA was 95.2% (40/42), with only 2 cases of recurrence at 2 months post-treatment.

Keywords: Microsurgery, botulinum toxin type A, conservative treatment, microsuturing

Introduction consists primarily of voice therapy to reduce the

Vocal process granuloma (VPG) is a benign lesion
affecting the vocal process of the arytenoid cartilage.
The pathogenesis of this disease is not understood,
but vocal abuse, intubation trauma, and gastroesoph-
ageal reflux (GER)/laryngopharyngeal reflux (LPR)
have been proven to be the main inducing factors. In
2010, Carroll et al. [1] presented evidence that glottal
insufficiency was the possible etiological factor in
patients with refractory VPG. Regardless of the eti-
ology, VPGs present similar clinical manifestations.
The most common symptom is hoarseness combined
with persistent throat clearing, sore throat, and a
globus sensation.
The optimal treatment regimen for VPG is still
controversial. The traditional treatment regimen
collision forces at the affected site and the adminis-
tration of anti-acids, such as proton-pump inhibitors
(PPIs), to prevent injury from GER. The other con-
servative treatments include botulinum toxin injec-
tion [2] and intralesional steroid injection [3]. In
2009, Wang et al. [4] demonstrated that most
VPGs (81%) spontaneously regressed and disap-
peared within 9 months. Although these treatment
regimens achieve desirable outcomes, the long course
of treatment, the persistence of the lesions, and the
side effects of the drugs made the patients anxious.
Surgery is not generally selected as the initial treat-
ment for VPG due to the high recurrence rate of this
lesion [5]. Surgery may be indicated to remove
obstructive lesions or lesions refractory to other ther-
apies. However, among all of the single treatment

Correspondence: Jun Wang, Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730,
China. Tel: +86 10 58269207. Fax: +86 10 65288441. E-mail: trentxy@163.com

(Received 11 September 2014; accepted 6 November 2014)

ISSN 0001-6489 print/ISSN 1651-2251 online
2015 Informa Healthcare
DOI: 10.3109/00016489.2014.986756
278 L. Ma et al.
strategies, surgical resection is the most rapid method
of eliminating granulomas.
Considering the multifactorial etiology of VPGs
and the advantages and disadvantages of different
treatments, some otolaryngologists have begun to
search for a combined therapy for VPG. Song et al.
[6] used surgical resection plus low-dose X-ray radi-
ation to treat refractory VPG. When Hong-Gang et al.
[7] used surgery and the administration of PPIs to
treat VPG, the recurrence rate was 38.7%. In partic-
ular, there was no recurrence among the patients who
had a recent history of intubation.
In this report, we describe the results obtained
when different VPG treatments were applied to deter-
mine which treatment was most efficacious.
Material and methods
For this study, 168 patients with VPG who were
treated in the Otolaryngology Head and Neck Surgery
Center of the affiliated Beijing Tongren Hospital of
Capital Medical University between January 2005
and January 2013 were enrolled. The diagnosis was
reached using rigid video-strobolaryngoscopy on an
outpatient basis. The medical records were reviewed
and data were collected, including the age, gender,
occupation, intubation history, history of GER or
LPR, symptoms or signs, previous treatment methods
applied, course of the treatments, and whether a
recurrence had presented. The granulomas were
graded using Farwell’s grading system according to
the laryngoscopic findings [8].
All the patients were given a conservative treatment
of omeprazole or esomeprazole (20 mg bid) admin-
istration for 3 months. The patients were told to
control their speaking, improve bad speaking habits,
and avoid unconsciously clearing the throat and
coughing during this period.
The patients for whom the conservative treatment
failed were treated with surgery. The patients treated
before 2009 were subjected to microsurgical resection
and microsuturing. These patients were subjected to
tracheal intubation under general anesthesia, using
1-2 gauze tracheal tubes that were smaller than those
used for general anesthesia. A self-retaining laryngo-
scope was usedto expose the lesion in the posterior of the
vocal cords (Figure 1A). Under a microscope, a radical
resection of the lesion and the surrounding neoplastic
tissue was conducted using micro-scissors and a 1.0 W
CO2 laser (Figure 1B). The cartilaginous membrane
surrounding the vocal process and the normal mucosa
surrounding the neoplasm were protected. The incision
was closed using 8-0 absorbable suture material
(Vicryl), using the interrupted apposition suturing
method to apply two to three stitches (Figure 1C).
A B
C D
Figure 1. Female, 48 years. (A) Image of the granulation-like
neoplasm on the vocal process of the right arytenoid, before the
resection was performed (arrow); (B) image of the same site after
the resection (arrow); (C) image of the incision site after closure
using an 8-0 absorbable suture filament (arrow); (D) diagram of the
sites of injection of botulinum toxin type A (red dots).
Since 2009, the VGA patients have been treated
using microsurgery combined with local injections of
botulinum toxin type A (BTA). After the granuloma
was removed, injections of BTA were given. The BTA
was diluted to 10 U/ml using a sterile saline solution.
A total of 8–15 U of BTA was injected into four points
of the thyroarytenoid and arytenoid muscles near the
arytenoid cartilage of the affected side. The BTA
injection sites are shown in Figure 1D (red dots).
For the thyroarytenoid injections, the injection needle
was aimed toward the side of the vocal ligament of the
mid-membranous vocal fold at the floor of the laryn-
geal ventricle. If lesions were found on both sides, the
left thyroarytenoid muscle was injected.
A budesonide inhalant was administered for 2 weeks
after the surgery and omeprazole or esomeprazole was
administered for 3 consecutive months after the surgery.
The patients who were injected with BTA under-
went stroboscopic laryngoscopy to observe the move-
ments of the arytenoid before surgery and at 3 days,
1 month, 2 months, and 3 months after surgery.
A voice assessment was conducted, which consisted
of a perceptual evaluation of HRB (the grade of
hoarseness, roughness, and breathiness) and deter-
mination of the maximum phonation time (MPT).
The perceptual evaluation was performed using a
four-point assessment scale, as follows: 0, normal;
1, mild; 2, moderate; and 3, severe. The voice assess-
ment was performed at 3 days, 1 month, and 3 months
after surgery. The mean follow-up period was
28 months, with a range of 12–58 months. The other
patients underwent stroboscopic laryngoscopy at
1 month and 3 months after treatment.

Statistical analysis
The paired-samples t test and the Wilcoxon signed-
rank test were performed to assess whether there were
significant differences in the MPTs and the HRB
grades before and at the last follow-up following
surgery. A value of p < 0.05 was considered to be
significant.
Results
There were 143 (85.1%) male and 25 (14.9%) female
patients with refractory VPG enrolled in this study.
Their ages ranged from 25 to 81 years, with an average
of 49 years. In 100 (59.5%) of the patients, the
granuloma originated on the left vocal process,
whereas 55 (32.8%) of the patients had a right-sided
granuloma. The other 13 (7.7%) patients had bilateral
VPG.
According to Farwell’s grading system, there were
12 (7.2%) cases of grade I granuloma, in which a
sessile, non-ulcerative granuloma was limited to the
vocal process; 36 (21.4%) cases of grade II granu-
loma, in which a pedunculated or ulcerated granu-
loma was limited to the vocal process; and
104 (61.9%) cases of grade III granuloma, in which
the granuloma extended past the vocal process but did
not cross the midline of the airway when the process
was in the fully abducted position. The other
16 (9.5%) patients were diagnosed with grade IV
granulomas, which extended past the vocal process
and past the midline of the airway when the process
was in the fully abducted position.
There were 57 (33.9%) patients with a history of
GER, 41 (24.4%) patients with a history of laryngeal
intubation for general anesthesia, 39 (23.2%) patients
who had used their voices excessively, 33 (19.6%)
patients with a history of smoking, and 19 (11.3%)
patients with no obvious etiology. Among the patients
with a history of laryngeal intubation for general anes-
thesia, there were 23 (16.1%) males and 18 (72%)
females.
A total of 148 (88.1%) of the patients had different
degrees of hoarseness, 111 (66.1%) patients had the
sensation of having a foreign body in the throat and a
cough, 29 (17.3%) patients had throat pain, and
16 (9.5%) patients had mild to moderate apnea.
Only five (3%) patients, who had no obvious symp-
toms, had VPG that was found upon physical exam-
ination. The symptoms of patients had lasted from
1 to 108 months (average of 12 months). The diag-
noses of the patients were confirmed by pathology of
specimens taken during the operations.
The lesions of 41.3% (71/168) of the patients who
were given the conservative treatment (including acid
Treatment methods for vocal process granulomas 279
suppression, vocal rest, and vocal therapy) disap-
peared and the lesions of 10.7% (18/168) of the
patients were reduced. The conservative treatment
was unsuccessful for 47% (79/168) of the patients.
The cure rate was 78.4% (29/37) in the patients who
were treated by microscope resection using a CO2
laser and microsuturing of the surrounding mucosa.
In the eight patients who experienced a recurrence,
five of the lesions disappeared after 3 months of
conservative treatment and another three patients
recovered after a second operation. The cure rate
of the other 42 patients who were treated using the
microsurgical operation combined with local injec-
tions of BTA was 95.2% (40/42). The two patients
who had a recurrence 2 months after the operation
refused a repeat surgery. At 1 year of follow-up, their
lesions were still present (Farwell class I) and the
patients did not have obvious symptoms.
The patients who were treated using BTA injec-
tions experienced hoarseness and breathiness for
2–3 days after the surgery. Using an electronic laryn-
goscope, we observed that the movements of the
arytenoid on the injected side were weaker than those
on the contralateral side. At 1 month after surgery, the
arytenoid on the injected side was fixed and the vocal
cord was arched. Therefore, there was a gap when the
glottis was closed (Figure 2). The arytenoid on
the injected side could move in 34 (80.95%) of the
patients at 2 months after the surgery, but the move-
ments were weaker than those on the opposite side.
The activity of the arytenoid was normal in eight
(19.05%) of the patients at this point. At 3 months
after surgery, the activity of the arytenoid on the
injected side was normal in all of the patients.
Compared with the preoperative values, the mean
MPT at 1 month after operation was significantly
decreased (p < 0.0001), by an average of 3.9 s, but
at 3 months after the operation, the mean MPT was
increased by 5.3 s. Compared with the value at
1 month after operation, the mean MPT at 3 months
after operation was increased by 9.2 s (Table I). There
was no significant difference in the roughness of the
voice at 1 month after operation and preoperatively,
but there was a significant difference between the
other scores at these points. In general, the postop-
erative HRB scores were better than the preoperative
scores (Table II).
Discussion
In 1935, Jackson and Jackson first described vocal
process contact granulomas, which are non-
tumorous granulation-like, proliferative tissue,
chronic inflammatory lesions located over the tip
of the cartilaginous region of the vocal processes
280 L. Ma et al.

A1 B1 C1

A2 B2 C2

Figure 2. Female, 48 years, with a granulation-like neoplasm on the vocal process of the right arytenoid. (A1, A2) Images showing the
movement of the bilateral arytenoid before the resection was performed; (B1, B2) images taken 3 days after the operation, showing that the right
vocal cord was arched and in a fixed position; (C1, C2) images taken 3 months after the operation, showing that the bilateral movements of the
arytenoid were normal.

Table I. Maximum phonation times (x ± s) of the patients (n = 42) [9]. In subsequent studies, the clinical manifestations
who were given botulinum toxin type A injections at different time and syndromes of VPG were found to be similar. The
points. main related syndromes are hoarseness, a sore throat,
Before 1 month after 3 months after and the sensation that a foreign body is present. Men
operation operation operation have a relatively higher incidence of this lesion than
women [10]; however, VPG caused by endotracheal
17.3 ± 6.3 13.5 ± 5.4* 22.6 ± 5.2*
intubation occurs more often in women. In the
*p < 0.01, paired-sample t test. present study, 148 (88.1%) patients experienced
various degrees of hoarseness, 111 (66.1%) patients
had the sensation of having a foreign body in the
throat and coughed, 29 (17.3%) patients experienced
Table II. HRB grades of the patients who were given botulinum throat pain, and 16 (9.5%) patients had mild to
toxin type A injections before the operation and 1 month and moderate apnea. Only five (3%) of the patients
3 months after the operation. with VPG exhibited no obvious symptoms upon
Before the 1 month after 3 months after physical examination. There were 23 (16.1%) males
Factor operation (%) operation (%) operation (%) and 18 (72%) females among the patients who had a
history of laryngeal intubation for general anesthesia,
Hoarseness
which was consistent with the results of previous
0 9 (21.4)* 2 (4.8)* 34 (80.95)* reports. The hypothesis of McFerran et al. was
1 16 (38.1)* 6 (14.3)* 8 (19.05)* that because women have a relatively narrow laryn-
2 11 (26.2)* 18 (42.9)* geal cavity and thin mucosa compared with those of
3 6 (14.3)* 16 (38.0)* men, women are more vulnerable to intubation-
Roughness
related injuries, which leads to the formation of a
vocal process ulcer that develops into granuloma
0 18 (42.9)* 15 (35.7) 35 (83.3)*
[11,12].
1 18 (42.9)* 24 (57.1) 7 (16.7)* Most studies have shown that phonation-based
2 5 (11.9)* 3 (7.1) injuries, injuries caused by laryngeal intubation,
3 1 (2.3)* and GER are the primary causes of VPG [13,14].
Breathiness In the present study, 6 patients had a history of
0 16 (38.1)* 1 (2.3)* 39 (92.9)*
laryngeal intubation, 8 patients had definitive GER
confirmed by 24 h pH monitoring or gastroscopy,
1 23 (54.8)* 6 (14.3)* 3 (7.1)*
4 patients had used their voices excessively, and
2 3 (7.1)* 18 (42.9)* 10 patients had no obvious etiology. The incidence
3 17 (40.5)* rate of VPG is low, and the three specific causes
HRB, grade of hoarseness, roughness, and breathiness. mentioned above are responsible for most of the
*p < 0.01, Wilcoxon signed-rank test. reported cases, which indicates that the main

mechanisms underlying the pathogenesis of VPG are
still not clear. In addition, these three causes fail to
account for the formation of idiopathic and recalci-
trant granulomas.
The treatments offered to patients with VPG are
driven by the etiology of the lesions. Because the
pathogenic mechanisms are unclear, the results of
treatments – particularly single therapies – are not
ideal. Conservative therapies, including correcting
bad phonation habits, voice rest, precautions against
reflux and/or medication using an H2-blocker, and
medication using a proton-pump inhibitor (PPI), are
the first-line treatments for VPG. The results of these
therapies are not satisfactory because the long-term
nature of the treatment and the occurrence of com-
plications and adverse reactions typically cause non-
compliance. Hanson et al. [15] reported 12 cases of
laryngeal granulomas treated with omeprazole, with
an average treatment time of 5 months. Wani and
Woodson [16] used omeprazole or ranitidine to treat
18 patients, among whom 14 cases had complete
remission after drug administration for 1–20 months,
with an average time of 10.4 months. In this study, the
efficiency of 3 months conservative treatment was
53%, which is lower than found in other studies.
This outcome may be due to our short observation
time, which was because the patients were eager to
improve their symptoms as soon as possible.
Surgery is always controversial. Physicians argue
that surgery should be used only in the patients for
whom conservative treatments have failed or in
patients with a large granuloma in the airway. The
reason for surgical excision being unacceptable is the
high recurrence rate; some studies have reported a
recurrence rate of up to 90%. The diagnosis of VPG is
performed using video laryngoscopy, but not biopsy.
Some of the patients who saw the mass in a video
recording were afraid of surgery, regardless of what
diagnosis we gave them. However, because the symp-
toms of VGA, such as hoarseness and a globus
sensation, are persistent, the patients are eager to
eliminate them by whatever means possible. Among
the single therapies, surgery is the most rapid method
for removing the granuloma and eliminating the
hoarseness and the sensation of the presence of a
pharyngeal foreign body. Physicians have been
searching for options that would lower the high recur-
rence rate of surgery. Hirano et al. [17] proposed
fiberoptic laryngeal surgery as a procedure that facil-
itated repeated surgical removal of these lesions. We
applied a CO2 laser to resect the lesion and closed the
incision using 8-0 absorbable suture filaments and the
interrupted apposition method, along the mucosal
edge in 23 patients with VPG, among whom the
recurrence rate was 21.6%. There was no recurrence
Treatment methods for vocal process granulomas 281
among the patients who had a recent history of
intubation. Microsurgical scissors and a CO2 laser
were used to perform a radical resection of the lesions
under a microscope. An 8-0 absorbable suture
filament was used to suture the mucosal edge of
the incision. Then, a four-point injection of 8–15 U
of BTA into the thyroarytenoid muscle of the
affected side was conducted. In the present study,
we applied a microsurgical suturing method using an
8-0 absorbable suture filament to close the wound,
promote healing, and reduce the probability of
recurrence. We also injected BTA into the concave
side of the muscle to limit the movement of the
arytenoid.
As a chemical denervation agent, BTA was first
used to treat spasmodic dysphonia [18]. In 1995,
Nasri et al. [2] were the first group to report treating
VPG by injecting BTA into the thyroarytenoid muscle
(LTA) and obtained a desirable level of efficacy. The
success of this therapy was confirmed by the subse-
quent serial studies. Treatment through BTA injec-
tion was the basis of the theory of the hammer and the
anvil as a cause of VGA [19]. Due to the force of
the collision of the bilateral arytenoid cartilage, the
mucosa of the vocal process is damaged, resulting in
the formation of a granuloma. Therefore, inhibiting
the movement of the arytenoid cartilage can facilitate
the repair of the mucosal injury and reduce the rate of
recurrence of VGA. BTA causes temporary paresis of
the vocal folds, allowing the mucosa of the vocal
process to regenerate. The total doses used ranged
from 5 U to 20 U. In the present study, the total dose
of BTA used was 8–15 U, which was divided into four
doses that were injected into the thyroidarytenoid
muscle. Our results showed that the activity of the
arytenoid on the injected side was limited for 2–3 days
after the injections were performed. The activity of the
arytenoid was generally normal at 2 months after
the injections were performed. The main side effect
of the BTA injections was a breathy voice. Voice
assessment revealed that the chemical denervation
of the ipsilateral thyroarytenoid muscle was apparent
12–72 h after the injection was performed, inhibiting
the adduction movement of the arytenoid muscle and
reducing the strength of the collision of the bilateral
vocal process. This state could persist for approxi-
mately 3 months, after which the denervated neuro-
muscular junction was fully recovered.
First, we removed the granuloma and closed the
incision through the surface of the arytenoid cartilage
using microsurgery. Then, we took advantage of the
denervating effect of BTA to inhibit the movement of
the arytenoid cartilage to reduce the force of collision.
Moreover, anti-acid medication was given to elimi-
nate the pathogenic factors of VPG.
282 L. Ma et al.
The treatment regimen for VPG should be targeted
and comprehensive due to the complexity and diver-
sity of the inducing factors. Only a comprehensive
treatment approach can shorten the treatment period,
improve the response rate, and reduce the rate of
complications and adverse reactions. Combined
therapy is considered to be the preferred choice for
treating refractory VPG.
Although VPG is a benign lesion, it affects patients’
quality of life due to its persistence and the long-term
nature of its treatment. An otolaryngologist should be
concerned about how to shorten the treatment pro-
cess and reduce the relapse rate. Surgical removal is a
rapid treatment method with a high recurrence rate.
Surgical resection combined with the use of other
conservative treatment methods may provide a bright
future for patients with this disease.
Acknowledgment
This study was supported by a grant from the
National Natural Science Foundation of China (no.
81170900).
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
References
[1] Carroll TL, Gartner-Schmidt J, Statham MM, Rosen CA.
Vocal process granuloma and glottal insufficiency:
an overlooked etiology? Laryngoscope 2010;120:114–20.
[2] Nasri S, Sercarz JA, McAlpin T, Berke GS. Treatment of
vocal fold granuloma using botulinum toxin type A. Laryn-
goscope 1995;105:585–8.
[3] Wang CT, Lai MS, Lo WC, Liao LJ, Cheng PW. Intrale-
sional steroid injection: an alternative treatment option for
vocal process granuloma in ten patients. Clin Otolaryngol
2013;38:77–81.
[4] Wang CP, Ko JY, Wang YH, Hu YL, Hsiao TY. Vocal
process granuloma – a result of long-term observation in
53 patients. Oral Oncol 2009;45:821–5.
[5] Ylitalo R, Lindestad PA. A retrospective study of contact
granuloma. Laryngoscope 1999;109:433–6.
[6] Song Y, Shi L, Zhao Y, Zhao D, Shi M, Deng Z. Surgical
removal followed by radiotherapy for refractory vocal process
granuloma. J Voice 2012;26:666; e1–5.
[7] Hong-Gang D, He-Juan J, Chun-Quan Z, Guo-Kang F.
Surgery and proton pump inhibitors for treatment of vocal
process granulomas. Eur Arch Otorhinolaryngol 2013;270:
2921–6.
[8] Farwell DG, Belafsky PC, Rees CJ. An endoscopic grading
system for vocal process granuloma. J Laryngol Otol 2008;
122:1092–5.
[9] Jackson C, Jackson CL. Contact ulcer of the larynx. Arch
Otolaryngol 1935;22:1–15.
[10] Lemos EM, Sennes LU, Imamura R, Tsuji DH. Vocal
process granuloma: clinical characterization, treatment and
evolution. Braz J Otorhinolaryngol 2005;71:494–8.
[11] Pontes P, De Biase N, Kyrillos L, Pontes A. Importance of
glottic configuration in the development of posterior laryn-
geal granuloma. Ann Otol Rhinol Laryngol 2001;110:765–9.
[12] McFerran DJ, Abdullah V, Gallimore AP, Pringle MB,
Croft CB. Vocal process granuloma. J Laryngol Otol 1994;
108:216–20.
[13] Orloff LA, Goldman SN. Vocal fold granuloma: successful
treatment with botulinum toxin. Otolaryngol Head Neck
Surg 1999;121:410–13.
[14] Spector JE, Werkhaven JA, Spector NC, Huang S, Page RN,
Baranowski B, et al. Preservation of function and histologic
appearance in the injured glottis with topical mitomycin-C.
Laryngoscope 1999;109:1125–9.
[15] Hanson DG, Jiang JJ. Diagnosis and management of
chronic laryngitis associated with reflux. Am J Med 2000;
108:112S–9S.
[16] Wani MK, Woodson GE. Laryngeal contact granuloma.
Laryngoscope 1999;109:1589–93.
[17] Hirano S, Kojima H, Tateya I, Ito J. Fiberoptic laryngeal
surgery for vocal process granuloma. Ann Otol Rhinol
Laryngol 2002;111:789–93.
[18] Blitzer A, Brin MF, Fahn S, Lange D, Lovelace RE. Botu-
linum toxin (BOTOX) for the treatment of “spastic dys-
phonia” as part of a trial of toxin injections for the treatment
of other cranial dystonias. Laryngoscope 1986;96:1300–1.
[19] Roh HJ, Goh EK, Chon KM, Wang SG. Topical inhalant
steroid (budesonide, Pulmicort nasal) therapy in intubation
granuloma. J Laryngol Otol 1999;113:427–32.
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