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Hoarseness of voice

Introduction:


Human voice is so complex that it not only conveys meaning, it also is capable of conveying subtle emotions.  It is the most important physiological aspect that effectively starts to function immediately after birth.


Definition:

Hoarseness of voice is defined as any change in the quality of human voice (lay terms).  This term utmost be considered to be a nonspecific one.  This term could imply breathiness, roughness, voice breaks or unnatural pitch changes.  Dysphonia is the corresponding term used by otolaryngologists to describe this condition.

“Hoarseness is a symptom of utmost significance
and calls for a separate consideration as a subject because
of the frequency of its occurrence as a distant signal of
malignancy and other conditions”

Chevalier Jackson

Causes of hoarseness of voice:


  • Inflammatory causes  including acute injuries
  • Mucosal disorders of vocal folds
  • Benign tumors of vocal folds
  • Malignant tumors of vocal folds
  • Laryngeal foreign bodies
  • Neurogenic causes affecting larynx

A useful Mnemonic to remember the causes of hoarseness of voice:
VINDICATE

V - Vascular (thoracic aneurysm)
I - Inflammation
N - Neoplasm
D - Degenerative (Amyotrophic lateral sclerosis)
I - Intoxication (smoking / alcohol)
C - Congenital
A - Allergies (angioneurotic oedema)
T - Trauma / Thyroid surgery
E - Endocrinology (Reidel's struma)

Inflammatory causes:


This is one of the commonest causes of hoarseness of voice.  Inflammatory causes could either be acute / chronic. 

Acute inflammatory causes: include acute laryngitis, acute epiglottis, acute laryngotracheal bronchitis, diphtheria etc.

Chronic inflammatory causes include: chronic non specific laryngitis (due to gastro oesophageal reflux disorders, vocal abuse etc).
Chronic specific laryngitis (tuberculous / syphilitic laryngitis).

Acute vocal cord injuries can lead to vocal fold tears / hematoma causing hoarseness of voice.  This condition resolves with complete voice rest.

Mucosal fold disorders:

Laryngeal oedema, Reinke's oedema.

Vocal nodule

Vocal cord polyp

Vocal cord cysts

Benign tumors:


Papilloma

Fibroma

Adenoma

Chondroma


Precancerous lesions:


Hyperkeratosis

Pachydermia

Leukoplakia

Malignant tumors of larynx:


Carcinoma vocal cords

Congenital conditions:


Congenital vocal cord webs

Foreign bodies




Vocal cord paralysis





Acute vocal fold tear



Hematoma of vocal cord



Reinke's oedema

Possible clinical presentations in patients with hoarseness of voice:


  1. Change in voice
  2. Cough
  3. Fever
  4. Vocal fatigue
  5. Irritation / soreness of throat
  6. Weight loss
  7. Painful vocalization
  8. Difficulty in swallowing
  9. Breathy voice
  10. Neck swelling
  11. Painful swallowing
  12. Heart burn / vomiting
  13. Haemoptysis
  14. Noisy respiration

Diagnosis:


Evaluation of hoarseness of voice should include:

Assessment of

Anatomy
Physiology
Behavioral factors

A complete history should be elicited.

Laryngeal visualization :  Indirect laryngoscopy / Direct laryngoscopy

Objective voice assessment: simplest method would be a tape recording of the voice in question.  This method should be considered to be
subjective.

Acoustic analysis: In this test voice is examined as electrical signals.  The term fundamental frequency is used to measure the number of
vocal fold  vibrations per second.  A normal adult male vocal cord vibrates between 100 - 130 Hz, where as in females it vibrates at the
rate of 200 - 230 Hz.  Abnormally high fundamental frequencies corrected for age and sex changes would indicate hyper contraction of
cricothyroid muscle representing a functional pathology or compensatory dysphonia.

Aerodynamic analysis:

The quality of voice is dependent on breath support.  Even subtle respiratory problems can lead to changes in voice.  Aerodynamic
measurements play a role in quantifying airflow during respiration and phonation.  Pulmonary function tests may play a role in
identifying subtle respiratory problems. 

     Maximum phonation time:  This is a measurement of the amount of time a patient can sustain a vowel sound in one breath. 
     Normal values range between 15 - 25 seconds.  Decreased values indicate incomplete glottic closure or insufficient lung support.

     Glottal air flow: This sensitive test captures the amount of air flowing through the glottis during phonation.  This is measured in
     cc/second by dividing the total volume of air flowing through the glottis by the amount of time in seconds.  This gives information
     about the lung capacity and the efficiency of vocal folds.  Increased glottal flow is associated with incomplete closure of glottis.
     The voice in patients with increased glottal flow is usually breathy / whispering in nature.
     Decreased glottal air flow is seen in patients with spasmodic dysphonia due to hyperadduction of vocal folds.

Management:


  1. Absolute voice rest - very useful in acute conditions
  2. Speech therapy - useful in chronic disorders
  3. Antibiotics
  4. Anti inflammatory drugs
  5. Treatment of GERDS
  6. Surgical intervention
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