Granulomatous conditions of the larynx constitute a heterogeneous group of lesions with overlapping symptoms. Many laryngoscopy findings are nonspecific, often confusing, with few systemic manifestations, and sometimes present as acute airway emergencies. It is imperative that the laryngologist suspects the possibility of such lesions when the presentation is atypical and the diagnosis does not “fit” in the classical scheme. Most cases may be managed conservatively avoiding an unnecessary tracheostomy. The correct approach undertaken at this time is crucial in determining the prognosis of the patient. An effective strategy involves multidisciplinary teams and a keen eye for systemic features, before undertaking any surgical intervention. Most granulomatous diseases show a definite regional preponderance but with the increase in immunocompromised conditions and globalization, this trend is changing worldwide. We retrospectively reviewed the data of 252 patients with suspected granulomatous lesions, seen over an 8-year period (2012–2020) at a tertiary care hospital with a voice clinic, in India. The epidemiological details, stroboscopy findings, histopathology, and response to treatment were noted. Some of the interesting cases with atypical presentations, which posed a diagnostic challenge, are discussed.