Hoarseness

Dysphonia

is defined as an impairment of voice, and can be divided into two categories; problems with projection of voice or problems with quality of voice. Hoarseness is one form of dysphonia that is defined as a rough or noisy quality of voice. However, hoarseness is often used interchangeably with dysphonia.

Importance: hoarseness is a symptom of both local laryngeal pathology and systemic disease. It is not only a distressing symptom for patients, but is also often the early presenting symptom of serious disease such as cancer of the larynx.

Mechanics of voice production

Anatomy

: The vocal apparatus of the larynx (the glottis) consists of a pair of true vocal cords that are lengthened, abducted and adducted by numerous muscles, thereby changing the tension of the cords and the amount of space between them. The musculature is innervated by 2 branches of the vagus nerve, the superior laryngeal and the recurrent laryngeal nerves (dominant supply).

Voice production

: During speech a column of air is passed through the adducted vocal cords, causing them to vibrate and produce sound that is shaped into articulated speech with the help of the oropharynx, tongue and lips. Any changes in the vocal cord or controlling structures may result in abnormal voice production by interfering with cord movement, approximation or vibration (organic dysphonia). On the other hand dysphonia may still be present with normal anatomy (functional dysphonia).

Organic

Organic

Infectious Inflammatory

• acute viral laryngitis
• bacterial tracheitis/laryngitis
• laryngotracheobronchitis

Non-infectious inflammatory (chronic irritation leading to vocal edema, nodules, contact ulcers or chronic laryngitis)

• gastro-esophageal reflux disease (GERD)
• smoke irritation
• chronic cough

Trauma- external laryngeal trauma

Neoplasia

• Benign:
  • Cysts ( retention cysts, laryngoceles , ventricular prolapse)
  • Tumors ( vocal cord polyps, papillomas, chondromas, lipomas, neurofibromas, hemangiomas)
• Malignant tumors (squamous cell carcinoma)

Systemic

• endocrine ( hypothyroidism, virulization)
• rheumatoid arthritis, SLE, sarcoidosis, wegner's granulotomosis, amyloidosis

Neurologic

• Central lesions (CVA, Guillain barre, head injury, MS, neural tumors)
• Peripheral lesions
  • Tumors: glomus jugulare, thyroid, bronchogenic, esophageal, neural tumors
  • Surgery: thyroid surgery, cardiovascular or thoracic/esophageal surgery (iatrogenic)
  • Cardiac : left atrial entargment, aneurysm of aortic arch
• Neuromuscular: myasthenia gravis, spastic dysphonia

Functional

Psychogenic aphonia ( hysterical aphonia)

Habitual aphonia

Ventricular dysphonias

Diagnosis:

History: take a full history keeping in mind the differential diagnosis to guide your questions

• ascertain the nature, onset and duration (acute or chronic) of the voice abnormality. Acute is usually considered to be less than 2 weeks.
• Are there times when the voice returns to normal? This would decrease the suspicion of a fixed lesion as the cause of hoarseness.
• Does the voice fluctuate throughout the day? This often is seen in patients with hoarseness 2° to GERD, with hoarseness worse in the am (lying supine).
• Precipitating Factors and Past medical history: was the hoarseness preceded by a viral URTI? Is there any history of trauma or recent screaming or yelling? Has the patient had thyroid, esophageal or cardiothoracic surgery? Does the patient have a history of hiatus hernia, GERD or hypothyroidism?
• Associated symptoms: dysphagia, odynophagia, hemptoysis, stridor, heartburn or symptoms of GERD, allergy symptoms, post-nasal drip, chronic cough, symptoms of hypothyroidism or airway compromise.
• Social History: smoking, alcohol use, vocal demands on the patient, their environment (level of noise, smoke or irritant toxins, do they use their voice excessively etc)
• Medication history: meds that dry the mucous membranes, cardiac meds producing a cough or hormones?

Physical

Do a complete ENT exam on the patient that presents with hoarseness.

one should always attempt to examine the larynx using either direct or indirect laryngoscopy, especially in the patient presenting with chronic dysphonia.

indirect laryngoscopy involves examining the larynx with a mirror, whereas direct laryngoscopy entails using a scope; either a rigid Hopkins scope or a fibroptic flexible laryngoscope

on laryngoscopy try to examine the vallecula, epiglottis, pyriform sinuses, false vocal cords, growths protruding from the ventricle, true vocal cords and immediately subglottic.

Examine the aforementioned areas for the colour and character of the mucosa, look for any lesions and their location, examine the vocal cords, and their resting position, demonstrate normal and symmetric abduction and adduction.

Stroboscopy (commonly not seen in a primary care office) can help the specialist increase detection of small undiagnosed lesions.

If you are unable to adequately view the larynx or its surrounding anatomy in a patient with a history that is not suggestive of a benign cause or a patient with chronic dysphonia, obtain an ENT consultation.

References

Berke G, Kevorkian K. The Diagnosis and Management of Hoarseness. Comprehensive Therapy. 1996; 22(4): 251-255,

Dettelbach M, Eibling D, Johnson J. Hoarseness: From viral laryngitis to glottic cancer. Postgraduate Medicine. 1994; 95(5): 143-163

Garrett C, Ossoff R. Hoarseness: Contemporary Diagnosis and Management. Comprehensive Therapy. 1995; 21(12): 705-710

Meyerhoff W L, Rice DH. Otolaryngology- Head and Neck Surgery. Philadelphia, Pa: W.B. Saunders; 1992.