We read with great interest the article by Aroor et al regarding cough while shaving after total laryngectomy. We have our own reservations regarding the diagnosis. We believe that the patient’s symptom most probably was caused by the traumatic neuroma of the internal laryngeal nerve.

Traumatic neuromas are very common after neck dissection. They are seen in up to 1.1% to 2.7% of the patients who undergo neck dissection . They most commonly arise from the cervical nerves causing pain and paresthesia. Although rare, traumatic neuromas arising from the internal laryngeal nerve have been described in the literature. To et al in their article published in 1986 have described a patient with similar complaints who was treated with the excision of the neuroma. Kus et al reported a patient with neuroma of the third and fourth cervical nerves who in addition to pain and paresthesia had spastic contraction of the face, neck, and shoulder.

The authors in their article do not provide any evidence to prove their diagnosis of cross innervation. Histopathologic examination of the excised “granuloma” would have given the diagnosis. Why was the specimen not sent for histopathologic examination?

The authors have also not mentioned the topographical distribution of the trigger points and their relationship with the relevant cervical nerve roots to call this cross innervation. The site of the “granuloma” in the photograph appears to be much medial to the carotids where the hyoid had been. The site appears similar to the one described by To et al in their article. Besides, any factor that increases formation of granulation tissue will increase the incidence of neuroma formation, as in this case .

Today, with high resolution (12-14-Mhz) ultrasonography, computed tomographic scan, and magnetic resonance imaging, traumatic neuromas can be differentiated from the recurrent lymph node especially when they are close to the carotids . People have tried various methods of treatment such as high ligation, steroid injection, and transfer of the nerves to unscarred site with varying success. Simple excision with ligation of nerve should suffice in most cases .

Patient’s symptoms, site of the lesion, and the response to treatment make the diagnosis of traumatic neuroma more likely. Without proper evidence, the theory of cross innervation may not hold much water. In this era of evidence-based medicine, beliefs and hypothesis need to be substantiated with scientific proof.