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CLINICAL PROFILE OF HOARSENESS OF VOICE

Sambhu Baitha1, R. M. Raizada2, A. K. Kennedy Singh3, M. P.


Puttewar3, V. N. Chaturvedi4

Key Words : Hoarseness, Clinical profile.

INTRODUCTION
The human voice is an extraordinary attainment, which is
capable of conveying not only complex thought but also
subtle emotion. At every child birth the most singularly
and universally awaited sign of life is the infants cry. The
cry signals a fulfilled physiological capability required for
the infants survival. Probably no other human organ
system need work so immediately and effectively after
birth. Although the voice is not visible to the eyes during
speech production but its absence or malfunction is
obvious(Colton et al, 1990).

except for the cases with change in voice due to (i)


Fig-1
Flow chart for clinical study of hoarseness

Hoarseness is the term used to describe a change in normal


voice quality. It is non-specific term, similar to patient's
complaint of dizziness when describing symptoms from
lightheadedness to true vertigo. Hoarseness may imply
breathiness, roughness, voice breaks or unnatural changes in
pitch. Term dysphonia is used by laryngologists to
describe abnormal voice quality. Complaints of hoarseness
may represent serious disease, therefore, should not be
ignored (Garrett et al, 1999). In the words of Chevalier
Jackson 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 (Parikh, 1991).
MATERIALS AND METHODS
The present study, comprising of 110 cases of hoarseness,
was carried out in the Dept. of Otolaryngology - HNS ,
MGIMS, Sevagram, Wardha (Maharashtra) between Jan.
1998 to Sept. 1999.
All the cases presenting to Otorhinolaryngology department
with history of hoarseness were included in this study

Registrar, 2Addl. Professor, 3Lecturer, 4Lecturer, 5Professor & Head, Dept. of Otolaryngology-HNS, M. G. I. M. S. Sewagram - 442 102,
India.

Clinical Profile of Hoarseness of Voice

15

Congenital disease (ii) Nasal & Nasopharyngeal pathology


(iii) Oral and oropharyngeal pathology and (iv) Speech
defects produced due to CNS lesions.
Methodology used for working up patients presenting with
hoarseness has been depicted in a Flow Chart (Fig - I)
OBSERVATIONS

I. Incidence of Hoarseness of Voice


A total of 34081 cases attended the ENT OPD (16472
new and 17609 old) between Jan 1998 to Sept. 1999. Out
of these 110 patients presented with hoarseness of voice.
Thus the incidence was noted to be 0.32% of all cases
and 0.66% of new OPD cases.
II. Clinical Profile of Hoarseness
1) Age: Majority of patients was seen in age group of 21-50
yrs. (61.81%) and most commonly in 4lh decade of life
(28.18%). The age of patients ranged from 6 yrs. to 71 yrs.
(Mean - 40.4 yrs. ) (Table-I).
2) Sex: Male predominance was observed, with Male:
Female ratio of 2: 1 (Table - I).
3) Occupation: Labourer class constituted single largest
group of patients (36.36%) followed by housewives
(21.81%), students (14.54%) and teachers (10%).
4) Rural / Urban distribution: Patients with hoarseness of
voice were predominantly from the rural areas comprising of
83 cases (75.5%). Only 27 (24.5%) patients were from the
urban area giving a rural : urban ratio of 3:1.
5) Duration of hoarseness: It was recorded in days, weeks,
Table I : Age & Sex wise distribution of patients with
Hoarseness

months and years. Duration of hoarseness ranged from 1


day to 5 years. (Mean - 3 months). Half of the patients
(50%), presented with duration in months.
6) Clinical presentation :
Symptoms : A part from the symptom of change in voice
(100%) other common presentations were cough, fever
and vocal fatigue in descending order of frequency. Other
symptoms which were noted are shown in Table -II. None
of the patients had aspiration or regurgitation.
Signs : a) Septic foci : Were noted in oral cavity &
oropharynx in 41.8% cases.
b) Indirect laryngoscopy: The most frequently
encountered laryngoscopic picture was congestion of true
vocal cords - seen in 27 (34.54%) patients followed by
presence of a nodule and thickening of vocal cord in 14
(12.72%) cases each and unilateral vocal cord paralysis in
paramedian position in 10 (9%) patients. Growth in
larynx was seen in 9 (8.18%) and polyp in 5 (4.54%)
cases . Congestion and edema of epiglottis, A. E. Folds,
interaytenoid area and false cords was also found on
indirect laryngoscopy.
c) Direct Laryngoscopy / Microlaryngoscopy: It was done
in 40 patients. Neoplastic lesions (Squamous cell

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. I, January - March 2002

16

Clinical Profile of Hoarseness of Voice

Table III : Incidence, Age & Sex distribution and Occupation of Patients as per different conditions causing
hoarseness of voice

carcinoma of larynx and laryngopharynx) were most


commonly encountered in 16 (40%) cases, followed by
vocal nodule in 9 (22.5%) cases. (Five cases of vocal
nodule either did not agree for direct laryngoscopy and
surgical treatment or were treated conservatively). Chronic
hyperplastic laryngitis was encountered in 6 (15%) cases.
Incidence, Age and Sex distribution and occupation of
different condition leading to hoarseness of voice are
shown in Table - III
DISCUSSION
In our study the incidence of hoarseness among total OPD
patients was 0.32% and incidence among new cases was
0.66%. The incidence of individual lesion leading to
hoarseness is shown in Table III. In the literature available to
us, incidence of hoarseness among patients attending
ENT OPD could not be found. This problem has been
encountered by some other workers also like - Mehta
(1985) who has mentioned that a search of available
literature on laryngology for the comparative incidence of
causes of hoarseness of voice was unfruitful Parikh (1991)
also comments Its strange that hoarseness as a subject
has not attracted the attention of many workers.
In our study the age of patients with hoarseness ranged
from 6 - 7 1 yrs. (Mean 40.4 yrs.) and the majority of

patients (61.81%) were in the group of 21-50 yrs. which is


considered as the most active period of life. Further,
patients in the 4lh decade (28.18%) constituted the single
largest group. Our observation is supported by Deshmukh
(1976) and Mehta (1985) who also reported the incidence
in the age group of 20 - 50 yrs. to be 63.1% and 67.2%
respectively.
Chopra and Kapoor (1997) reported the incidence of
benign glottic lesions undergoing microlaryngeal surgery
in the age of 20 - 50 yrs. to be 73.14%. Contrary to this, a
low incidence of 58% in the above age group was noted by
Saxena and Gode (1975) in their study on cases
subjected to Microsurgery of the larynx. Both these studies
involve a limited group of patients in whom focus of
attention is benign glottic lesions or microsurgery of
larynx, which is not the case with our study.
A male : female ratio of 2:1 was observed in this study.
Our finding is exactly in confirmation with that of Parikh
(1991). Other studies by Deshmukh (1976), Vrat et al
(1981) and Mehta (1985) also showed male predominance.
As far as occupation is concerned, Labourers constituted
the single largest group of patients (36.36%) in our study
followed by housewives comprising 21.81% cases.
According to Chopra and Kapoor (1997) only 5.97% their

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 1, January - March 2002

Clinical Profile of Hoarseness of Voice

17

patients presenting with benign glottic lesions (for


microlaryngeal surgery) were farmers. The high incidence of
hoarseness among labourers in our study may be
explained by the fact that our hospital being rural based
caters mostly to the village population comprising of farm
labourers.

64% cases respectively). We have found vocal cord polyp


(4.5%) on right side in 40% patients and left side in 60%
patients. Probably it requires study on large number of
cases to arrive at any conclusion. It is already mentioned
earlier that direct laryngoscopy and / or
Microlaryngoscopy were done in 40 patients.

Mehta (1985) and Hirschberg et al (1995) have reported


higher incidence of voice disorders among the urban
population. However in our study hoarseness of voice
was predominantly seen in rural inhabitant with rural :
urban ratio of 3:1. (Reason already mentioned above).
Duration of hoarseness ranged from 1 day (acute onset
cases) to 5 yrs. and 50% patients had duration of
hoarseness in months. Chopra and Kapoor (1997) have
noted 68.65% patients with duration of hoarseness of less
than one year.

As per Table III, the most common condition accounting


for slightly less than half of all cases with hoarseness
(49%) was found to be chronic laryngitis followed by
acute laryngitis (26.3%). Others were neoplasms (14.5%),
vocal cord palsy (9%), trauma and senile larynx (1.8%
each).

The present study on hoarseness of voice included all the


patients with symptom of change in voice (100%). Mehta
(1985) and Parikh (1991) have also done similar studies
and noted that 100% cases presented with hoarseness.
As in our study the other associated symptoms like cough,
dyspnoea, dysphagia, throat pain, weight loss etc. were
noticed by Parikh (1991) also.
In the study by Shah (1973) on patients with benign
growths of larynx incidence of hoarseness was reported to
be 93% and the other symptoms were cough, painful
swallowing, difficulty in swallowing, fever, lump in throat
and respiratory distress.
Among signs on clinical examination septic foci in the
oral cavity and oropharynx were observed in 41.8% of
our cases. This is in agreement with Mehta (1985) and
Parikh (1991) who reported oral and oropharyngeal septic
foci in 43% of their patients with hoarseness. Kaluskar
(1971) reported a higher incidence of septic foci (59%) in
patients with hoarseness of voice. Indirect laryngoscopy
findings have already been mentioned before.
Parikh (1991) reported vocal cord nodule as the most
common finding (50%) among patients with chronic
laryngitis and the nodules were bilateral in 91% cases. In
our series vocal cord nodules were seen in 12.72% patients
and they were bilateral in all the cases (100%). Mehta
(1985) also reported bilateral vocal cord nodule in 100%
cases. Further, both the authors reported vocal cord polyp
to be more common on the right vocal cord (72.67% and

Summary
Incidence of hoarseness of voice was observed to be
0.32% of all OPD cases and 0.66% of all new case
attending Otolaryngology and Head and Neck Surgery
OPD. Patient's age ranged from 6 -7 1 yrs. (Mean 40.4%
yrs.) Male: Female ratio was noted to be 2:1. Labourers
constituted the single largest group of patients comprising of
about 36% cases. Three fourth of patients were from the
rural area. Duration of hoarseness ranged from 1 day
(Acute onset) to 5 yrs. (mean - 3 months). Septic foci in
oral cavity and oropharynx were noted in 41.8% cases.
Apart from change in voice other common symptoms
were cough, fever and vocal fatigue. Signs of chronic
laryngitis were noted in roughly half of the cases.
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Deshmukh (1976): Clinical study of hoarseness of voice: A thesis


submitted for Master of Surgery (Otorhinolaryngology), Gujarat
University .

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(Otorhinolaryngology), Gujarat University.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 1, January - March 2002