Dr. Morton Cooper reports outstanding results from using Direct Voice Rehabilitation (DVR) with Contact Ulcers and Granulomas of the Larynx. Covering over 200 cases between 1961 and 2005, his success ratio is excellent (90%+).

Dr. Cooper’s success and cures of this condition were detailed in his textbook Modern Techniques of Vocal Rehabilitation in 1973. From that time on, Dr. Cooper reports faster results because of discoveries he has made with locating the right pitch of voice, the right placement of voice, the better way to breathe right for speaking, and focusing in on the voice image and voice identity, which he finds are all key to successful voice rehabilitation.

Overview of Contact Ulcers

Jackson defined the condition of contact ulcer in 1928. However, Virchow referred to a condition similar to contact ulcer as “pachydermis laryngis” in 1858. A contact ulcer is a lesion which occurs on one or both of the medial surfaces of the arytenoid cartilages. In incipient contact ulcer, edema inflammation or redness is present.

As the contact ulcer develops, the interarytenoid area consists of “an area of exposed necrotic cartilage surrounded by a rim of raised granulation tissue” as, described by Cooper and Nahum (1967, p. 41-46).

According to these authors, contact ulcer develops in three stages, the first stage being incipient contact ulcer:

The first stage is manifested by fatigue and hoarseness which occur at the end of the day or after periods of voice stress. The amount of trauma required to produce the symptoms gradually decreases. Voice rest, usually at night or on weekends or vacations, results in recovery and loss of the symptoms, but they recur more frequently as time goes on. Examination discloses minimal edema and redness of the interarytenoid area and is seen only when the patient has recently abused his voice. With rest the appearance returns to normal.

In the second stage there is continual hoarseness, fatigue, and occasional pain on speaking or swallowing, and rest affords only temporary relief. Examination show severe inflammation with early loss of the mucoperichondrium covering of the opposing arytenoid surfaces.

In the third stage there is severe constant hoarseness, fatigue, pain on swallowing or talking, and little relief with the mere rest. Examination shows a denudation of the opposing cartilaginous surfaces and a surrounding rim of granulation tissue. (1967, p. 42)

Types of Contact Ulcers

Three different pathological conditions of contact ulcers have been encountered.

The first type is an incipient contact ulcer and is treated by voice rehabilitation alone.

The second type is the benign contact ulcer granuloma or fossa which is the type that prevails most frequently. The granuloma may be treated by surgery prior to voice rehabilitation, but the fossa is usually treated by voice rehabilitation alone.

The third type is the contact ulcer granuloma which has undergone malignant degeneration. This type is diagnosed by biopsy and treated by surgery and/or radiation followed possibly by voice rehabilitation.

Treatment Methods

Since contact ulcer of the larynx is due mainly to voice misuse and abuse, a major approach to the treatment is voice rehabilitation. This disorder was initially treated with voice rehabilitation by Peacher (1947c).

Some authors have maintained that emotional tension is the central cause of the contact ulcer. Arnold postulates: “Contact ulcer is a psychosomatic disease resulting from emotional tension” (1966, p. 80). In a follow-up of 70 cases, Peacher notes that superficial psychotherapy was adequate for most patients and only a small number required psychotherapy (1961). A review of this author’s patients confirms Peacher’s findings regarding psychotherapy. However, voice psychotherapy was vital for all contact ulcer patients seen.

Jackson and Jackson find that nearly all contact ulcer patients dated the onset of their laryngeal symptoms from a cold or influenza (1935a). Holinger and Johnston also note that 26 out of 92 patients attributed the onset of the symptoms to an acute upper respiratory condition (1960).

Jackson and Jackson warn that the condition is usually overlooked (1935a). Cooper and Nahum recommend that the physician watch for the patient who is in the incipient or first stage of contact ulcer (1967). They continue:

Patients in the early stages are the easiest to treat and good results can be obtained relatively early, which prevents the long-term problems associated with advanced cases. (p.42)

Treatment Using Voice Rehabilitation

The treatment of contact ulcer by voice rehabilitation affords excellent results. The usual duration of therapy falls within six to twelve months for a resolution of the lesion. (A shorter period of time may eliminate the problem in some cases.)

The contact ulcer patient is almost invariably at the basal or near-basal pitch of voice. The tone focus is usually in the laryngopharynx. Poor voice hygiene often accompanies the voice misuse, adding to or even initiating the condition itself. (Therapy for this condition is the same as has been described.)

Clinical Results

Of the 85 patients seen with contact ulcers, the following conclusions may be drawn:

  1. Of the 85 patients seen, 61 (71.8%) entered therapy.
  2. Of the 61 patients entering therapy, 56 (91.8%) completed therapy.
  3. Of the 56 patients completing therapy, 25 (44.6%) had long-term therapy and 31 (55.4%) had short-term therapy.
  4. Of the 56 patients completing therapy, the results were: 49 (87.5%) excellent, 5 (8.9%) good, and 2 (3.6%) fair.
  5. The comparison between males and females seen: 66 (77.6%) males and 19 (22.4%) females.


A few examples of former Contact Ulcer Granuloma patients: