Академический Документы
Профессиональный Документы
Культура Документы
Hoarseness
a guide to voice disorders
Hoarseness is usually associated with an upper respiratory tract infection or voice overuse
and will resolve spontaneously. In other situations, treatment often requires collaboration
RON BOVA Voice disorders are common and attributable to Inflammatory causes of voice
MB BS, MS, FRACS a wide range of structural, medical and behav- dysfunction
JOHN McGUINNESS ioural conditions. Dysphonia (hoarseness) refers Acute laryngitis
FRCS, FDS RCS to altered voice due to a laryngeal disorder and Acute laryngitis causes hoarseness that can result
may be described as raspy, gravelly or breathy. in complete voice loss. The most common cause
Dr Bova is an ENT, Head and Intermittent dysphonia is normally always secon- is viral upper respiratory tract infection; other
Neck Surgeon and Dr McGuinness dary to a benign disorder, but constant or pro- causes include exposure to tobacco smoke and a
is ENT Fellow, St Vincents gressive dysphonia should always alert the GP to short period of vocal overuse such as shouting or
Hospital, Sydney, NSW. the possibility of malignancy. As a general rule, a singing. The vocal cords become oedematous
patient with persistent dysphonia lasting more with engorgement of submucosal blood vessels
than three to four weeks warrants referral for (Figure 3).
complete otolaryngology assessment. This is par- Treatment is supportive and aims to maximise
ticularly pertinent for patients with persisting vocal hygiene (Table), which includes adequate
hoarseness who are at high risk for laryngeal can- hydration, a period of voice rest and minimised
cer through smoking or excessive alcohol intake, exposure to irritants. Antibiotics are not indicated
and for patients with a family history or personal if a viral infection is suspected, and corticosteroids
history of head and neck cancer. are rarely indicated for this common condition.
The mechanism of voice production is Effortful speaking or singing during an acute attack
described in the box on page 39. of laryngitis may lead to vocal cord haemorrhage
IN SUMMARY
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.
How is voice produced?
Voice production is a complex process requiring co-ordination between the lungs, larynx, pharynx and oral cavity. The lungs act like a power
source, blowing expired air up through the vocal cords in the larynx (Figures 1a and b). The vocal cords vibrate hundreds of times per second,
producing sound, the resonance of which is modified by muscular activity in the pharynx and oral cavity. Normal voice requires functioning vocal
cords that are lined by smooth, well hydrated epithelium (Figure 2). Even the slightest alteration in vocal cord structure can result in hoarseness.
Tongue Epiglottis
Epiglottis
Trachea
False vocal Laryngeal
cord copyright ventricle
True vocal
cords
Figure 1a (top left). Laryngeal structures as seen from above during examination.
Figure 1b (top right). Coronal section through the larynx. Note the true vocal
cords are separated by a space (laryngeal ventricle) from folds of supraglottic
tissue (false vocal cords).
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.
Hoarseness
continued
Laryngopharyngeal reflux, which occurs when acid refluxes through an incompetent upper oesophageal sphincter and irritates the larynx, is a
common cause of chronic laryngitis. Even small amounts of acid reflux can cause minor laryngeal oedema resulting in hoarseness in addition
to the other symptoms of chronic laryngitis, especially chronic throat mucus clearing and dry cough. Despite having concurrent gastro-
oesophageal reflux disease (GORD) due to lower oesophageal sphincter dysfunction, patients may not complain of heartburn or chest pain
because the oesophageal mucosa is much more resistant to small quantities of acid reflux.
A classic feature of severe laryngopharyngeal reflux is granulation tissue overlying the
posterior vocal cord but this is relatively uncommon; a reflux granuloma is shown in Figure 4.
Treatment for chronic laryngitis due to laryngopharyngeal reflux is an eight- to 12-week
empirical course of a proton pump inhibitor as well as dietary and lifestyle modification,
including elevation of the head of the bed. Speech therapy is useful, especially for patients
with reflux granulomas, and aims to modify vocal cord closure patterns to minimise
contact trauma between the posterior cords. Microsurgical removal is sometimes required
for granulomas that are large or refractory to conservative measures. A relatively new
treatment for stubborn granulomas involves paralysing the affected vocal cord by injecting
botulinum toxin type A (Botox, Dysport). This minimises phonatory trauma and allows the
Figure 4. Reflux induced granuloma of the left granuloma to resolve, but severe breathy dysphonia lasting months is unavoidable.
posterior vocal cord. This lesion and the patients Patients with severe or persistent reflux symptoms refractory to medical management
symptoms resolved with antireflux therapy. may require comprehensive evaluation by a gastroenterologist.
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.
Hoarseness
continued
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.
Hoarseness
continued
vocal cords or infiltration into the intrinsic The most common form is adductor neck along the tracheo-oesophageal
muscles of the larynx. Initial symptoms are spasmodic dysphonia, in which there is groove and is intimately associated with
often subtle, so patients frequently present increased closure of the vocal cords the back of the thyroid gland). Less com-
with advanced disease. Common present- resulting in speech that is punctuated by monly, the vagus nerve may be paralysed
ing symptoms include stridor, hoarseness, frequent strangulated and constricted higher in the neck or skull base, resulting
haemoptysis and dysphagia. Cervical neck stops. Intelligibility of the patient may be in palatal asymmetry in addition to vocal
nodal metastasis is very common with impaired markedly. Abductor spasmodic cord paralysis. Patients present with a
supraglottic cancers, and hence patients dysphonia, in which sudden increased breathy voice, reduced vocal pitch and
may present with a neck lump. Treatment opening of the vocal cords occurs and significant vocal fatigue. The paralysed
involves surgery, radiotherapy or com- results in a breathy voice, is far less com- cord often lies in an open position, result-
bined modality therapy. mon. Other neurological symptoms are ing in a large glottic gap that can lead to
sometimes present in patients with spas- significant aspiration.
Neuromuscular disorders modic dysphonia, including tremors and The common causes of vocal cord
Muscle tension dysphonia facial dystonia. paralysis are:
Muscle tension dysphonia is a relatively Treatment of spasmodic dysphonia has iatrogenic (thyroid or thoracic surgery)
common yet poorly understood cause of been revolutionised by injection of botu- idiopathic although unproven, viral
hoarseness. It is thought to result from linum toxin type A to temporarily paralyse neuritis is suspected to be a relatively
excessive and unnecessary tension of the hyperfunctioning muscle group. This common aetiological factor because
laryngeal muscles during phonation. On is done as an outpatient procedure using recurrent laryngeal nerve palsy often
examination, patients typically constrict electromyographic guidance. Excellent occurs after an upper respiratory tract
their supraglottic laryngeal muscles to the results lasting three to four months can be infection
point where it can be difficult to visualise expected. cancer (thyroid, laryngopharynx,
their vocal cords during vocalisation. It lung, oesophageal)
may develop as a compensatory vocal Presbyphonia thoracic aortic aneurysm
technique in patients with glottic insuffi- Presbyphonia is hoarseness resulting from cerebrovascular accident, head trauma
ciency such as age related vocal atrophy; age related laryngeal changes. It is very (central vagal paralysis).
alternatively, it may occur as a primary common in elderly patients and charac- When the cause is unknown, patients
imbalance of laryngeal muscle use. It is terised by an intermittent hoarse, breathy require a comprehensive radiological
thought to be compounded by stress or or wavery voice that often fatigues easily. assessment of the head, neck and chest to
anxiety. Laryngeal muscle atrophy results in the exclude malignant infiltration of the vagus
The major complaint is usually fluc- vocal cords having a bowed appearance or its recurrent laryngeal nerve branch.
tuating hoarseness and vocal fatigue, and, in combination with age related loss Subsequent management depends on the
sometimes with a feeling of tightness or of vocal cord tone and elasticity, leads to cause of the nerve palsy. The treatment
discomfort in the throat. It is important varying degrees of hoarseness. Elderly options to rehabilitate the paralysed vocal
to ask about reflux laryngitis because this patients may also be taking medications cord include:
may be an exacerbating factor in a signif- with anticholinergic side effects, which Nonsurgical management. If there is no
icant number of patients. Speech therapy contribute to vocal dryness. aspiration and the patient is happy
to reduce excessive laryngeal tension Speech therapy helps to increase laryn- with the voice, the paralysed cord can
during voice use is the cornerstone of geal muscle tone and improve voice qual- be left alone with the expectation that
management. ity. Injection of fat or synthetic materials partial compensation will occur after
into the vocal cords is possible in severe approximately six months. In cases
Spasmodic dysphonia cases, but it is rarely indicated. where the nerve is bruised or
Until relatively recently, spasmodic dys- temporary neuritis is suspected after
phonia was considered a psychiatric diag- Vocal cord paralysis an upper respiratory tract infection,
nosis. It is now recognised as a regional Vocal cord paralysis most commonly complete recovery can be expected.
dystonic reaction of the larynx charac- occurs as a consequence of paralysis of the Injection thyroplasty. This involves
terised by involuntary spasms of the vocal recurrent laryngeal nerve (a distal branch injection of fat or artificial substances
cords. Like many dystonic reactions, it of the vagus nerve that innervates the (Gelfoam, Teflon) into the paralysed
is absent at rest (therefore breathing is intrinsic laryngeal muscles and ascends vocal cord to medialise it in an
normal) but precipitated by speaking. from the mediastinum into the root of the attempt to reduce the glottic gap. The
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.
procedure requires a short general patient who smokes or has a high alcohol
anaesthetic and has minimal intake and when it is associated with other Who wants your opinion?
morbidity. throat symptoms such as dysphagia,
Laryngeal framework surgery. This stridor or haemoptysis. Radiological WE DO. Did you find a particular
involves insertion of a Silastic or investigations such as CT scans detect article in this issue helpful in your
Gortex implant into the vocal cord via only large lesions and miss the majority of practice? Do you have something to
a small window through the thyroid vocal cord lesions. Flexible endoscopic say about an article we have
cartilage resulting in medialisation of nasolaryngeal examination is the most published or some of the opinions
the paralysed cord. The procedure can sensitive investigatory tool and can be per- expressed? Write and tell us, and we
be performed under local anaesthetic formed easily in the office setting. Treat- will consider your letter for
and requires an overnight stay in ment varies according to the cause but publication. We are more likely to
hospital. often requires collaboration between GP, print short letters (no longer than 250
ENT surgeon and speech pathologist. MT words), so please be succinct.
Final comments Write to: Medicine Today,
Everyone experiences hoarseness at some Reference PO Box 1473, Neutral Bay, NSW 2089
time in their lives. Fortunately it is usually
associated with an upper respiratory tract 1. Silverberg MJ, Thorsen P, Lindeberg H, Grant
infection or voice overuse and will resolve LA, Shah KV. Condyloma in pregnancy is strongly
spontaneously. Persistent unexplained predictive of juvenile-onset recurrent respiratory
hoarseness should alert the GP to the pos- papillomatosis. Obstet Gynecol 2003; 101: 645-652.
sibility of a benign or malignant laryngeal
lesion, especially when it occurs in a DECLARATION OF INTEREST: None.
Permission granted for use by Entthyroid.com.au for educational purposes. Medicine Today 2007. Copyright for illustrations as stated.