#12136 - Hoarseness - ENT

Hoarseness

What is a normal voice?

• One that is

  • Audible in a wide range of acoustic settings

  • Appropriate for gender and age

  • Capable of fulfilling its linguistic and paralinguistic functions

  • Not easily fatigued

  • Not associated with phonatory discomfort/pain

Pathophysiology

• Vocal cords are attached anteriorly to the thyroid cartilage and posteriorly to the arytenoid cartilages

• Intrinsic laryngeal muscles abduct cords for respiration and adduct the cords for lower airway protection, cough and phonation

• Vocal cords = mucosal folds

  • Have a superficial layer of epithelium separated from the underlying ligament and muscle by ‘reinke’s space’

    • Allows epithelial layer to slide and osscilate passively over the ligament

Larynx is divided into three regions

• Supraglottis

• Glottis

• Subglottis

Aetiology

• Voice problems can be classified into

  • Structural/neoplastic

  • Inflammatory

  • Neuromuscular

  • Muscle tension imbalance

Referal

• As a laryngeal visualization is often necessary, most patients need referring

• Patients with persistent hoarseness/voice change for > 3 weeks (especially if a smoker, heavy drinker + >40 years) need urgent CXR to exclude RLN palsy from lung cancer + referral to ENT surgeons

Assessment

• History

  • Specific voice problem e.g abnormal quality, pitch etc

  • Onset, duration

  • Constant/intermittent

  • Relieving/exacerbating factors

  • Voice requirement e.g fine precision + control/voice projection/continuous use

  • Past medical history

  • Drug history – reduced laryngeal secretions + mucosal drying = anticholinergics, diuretics. Irritant = bronchial inhalers

Examination

• Flexible nasoendoscopic examinations allow visualization of vocal tract

• Examine for neck masses

• Electromyography is helpful in detecting paresis and distinguishing cricoarytenoid joint fixation from vocal cord palsy

• Larynogopharyngeal reflux can be investigated by 24 hour pH measurements

Management

• Depends on diagnosis

• Options include

  • Reassurance and education

    • Vocal hygiene – drink 2 L a day, avoid irritants, avoid throat clearing, avoid damaging voice, use steam inhalers

    • Stop smoking + reduce alcohol intake

  • Medical treatment

  • Voice therapy

    • Relaxation techniques, improve efficiency of voice

  • Specialist therapy

    • Singing lessons

  • Surgery

Structural/neoplastic conditions

• Benign nodules

  • Reinke’s oedema

• Malignant: SCC

• Enodcrine: Hypothyroidism, androgenic

• Inflammatory: Rheumatoid deposits, amyloid deposits

Diagnosis follows videolaryngostroboscopy

Management: Sometimes vocal hygiene, voice therapy + treatment of any inflammation is enough. Surgical resection can be required

Inflammatory conditions

• Infective

  • Laryngitis – viral/bacterial/fungal

  • URTI
    LRTI

• Non-infective

  • Laryngopharyngeal reflux

  • Allergy

  • Trauma/irritation

  • Drugs

  • Autoimmune e.g sjogrens syndrome

Neuromuscular conditions

• Hypofunctional: parkinson’s disease, myasthenia gravis

• Hyperfunctional: chorea, spasmodic dysphonia

• Mixed: vocal cord palsy, MS, MND

• Control/co-ordination: tremor, myoclonus

Muscle tension imbalance conditions

• Primary imbalance follows increased demands on voice/poor vocal technique

• Secondary imbalance occurs due to the other problems e.g inflammation/structural/neuromuscular

Acute laryngitis

• Common

• Associated with URTI

• May be non-infective e.g after shouting

• Usually painful

• Spontaneous resolution

• Steam inhalation may provide symptom relief

Chronic laryngitis

• Long term effect of

  • Continuing vocal abuse

  • Alcohol ingestion

  • Inhalation of tobacco smoke

• Resp. epithelium replaced by metaplasia with keratinizing squamous lining

• Larynx macroscopically shows hypertrophic epithelium + leukoplakia

Laryngeal nerve palsy

• Recurrent laryngeal nerve (RLN) supplies all the intrinsic muscles of the larynx + is responsible for both adduction and abduction of the cords

• RLN originates from the vagus

  • LRLN more often damaged as hooks around the aortic arch (longer)

  • RRLN hooks around the subclavian artery (shorter)

• Symptoms of RLN palsy

  • Hoarseness

  • Breathy voice, weak cough

  • Repeated coughing due to aspiration

  • Exertional dyspnea

• Aetiology

  • Cancer (30% - larynx, thyroid, oesophagus, lung)

  • Iatrogenic (25% - e.g thyroidectomy)

  • CNS disease

  • TB

  • Aortic aneurysm

• Investigations

  • CXR, barium swallow, MRI

• Management: depends on underlying cause

Laryngopharyngeal reflux

• Chronic laryngeal signs + symptoms...