Lateral Cricoarytenoid–Dominant Closure Pattern Causing Recurrent Granulomas

A 63-year-old man presented to our office for intermittent hoarseness following vocal performances. He also reported associated cough, postnasal drip, and heartburn symptoms. Strobovideolaryngoscopy revealed reflux laryngitis, bilateral vocal fold granulomas, right vocal fold paresis, and a lateral cricoarytenoid (LCA)-dominant closure pattern. Initially, we recommended voice therapy and treatment of reflux with a proton-pump inhibitor, H2 blocker, and lifestyle modifications. An extensive review of granulomas supports the relationship of granulomas to reflux. ¹ Despite treatment, follow-up strobovideolaryngoscopy demonstrated persistent granulomas and LCA-dominant closure pattern (Figure 1). Because of this closure pattern, botulinum toxin was injected in the LCA in order to weaken the muscle and prevent forceful contact between the vocal processes. This intervention facilitates effective voice therapy, promotes healing, and decreased the risk of recurrence if surgery is required.

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Figure 1.

Right greater than left vocal process granulomas.

Vocal fold adduction is achieved through the activation of the LCA, interarytenoid (IA), and thyroarytenoid (TA) muscles. The TA muscle plays an important role in anterior vocal fold adduction and contraction results in a completely closed anterior glottis. Lateral cricoarytenoid contraction causes a medial and downward rocking motion of the arytenoid cartilage which adducts the posterior portion of the glottis, bringing the vocal processes together. ² Lateral cricoarytenoid and IA muscle contraction results broader closure of the cartilaginous portion of the glottis between the vocal processes and posterior portion of the larynx. In some patients, there is an imbalance in activity between the LCA and IA muscles during adduction. Dominance of the LCA activity results in forceful point contact near the tip of the vocal processes, which can lead to persistent granulomas and contributes to hoarseness as seen in this patient (Figure 2). Botox can be injected in order to weaken the LCA activity in patients with LCA-dominant closure and prevent this repetitive forceful point contact between the tips of vocal processes. The restored balance between the LCA and IA generally will result in broader contact between the cartilaginous portions of the focal folds during phonation and often allows resolution of the granulomas.

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Figure 2.

Lateral cricoarytenoid–dominant closure pattern causing forceful point contact at vocal processes before closure of the cartilaginous portion which was complete in the next frame of the video (not shown).