Hoarseness: Causes, Diagnosis, and Management - PDF

HOARSENESS: Dr Olaniyan O David LTH Ogbomoso Introduction Hoarseness is a general term that describes abnormal voice changes. Hoarseness is defined as roughness, or breathy quality of the voice It is a symptom not a diagnosis. Goal of management is to determine the underlying...

HOARSENESS: Dr Olaniyan O David LTH Ogbomoso Introduction Hoarseness is a general term that describes abnormal voice changes. Hoarseness is defined as roughness, or breathy quality of the voice It is a symptom not a diagnosis. Goal of management is to determine the underlying cause and treat it.  Any case of hoarseness needs to be referred to an ENT specialist Introduction The voice is an essential tool for communication A means of livelihood and entertainment Chronic non-specific laryngitis including vocal nodules was the most common cause (55.6%), Laryngeal cancers- 24.2% Recurrent laryngeal nerve palsy- 8.1% Laryngeal papilloma- 6.5% 60.88% were Professional singers Causes of hoarseness, Causes of hoarseness TB Laryng, 2% Chronic Laryngitis, 28% Laryng Ca., 19% Laryng Polyp, 3% Resp. Papil, 6% Acute Laryngitis, 6% LPR, 36% Chronic Laryngitis LPR Acute Laryngitis Resp. Papil Laryng Polyp Laryng Ca. TB Laryng Causes of hoarseness Inflammatory Chronic laryngitis Tuberculous laryngitis Allergic laryngitis Inflammatory polyp Acute laryngitis Pemphigus vulgaris of larynx Chronic laryngitis with vocal nodule  Trauma Voice abuse/excessive voice use Vocal cord nodule from excessive voice use Trauma from metallic foreign body Blunt trauma to larynx Tumour Squamous cell carcinoma of larynx  Nasopharyngeal carcinoma with laryngeal extension Vc sq. cell papilloma/lymphoid hyperplasia with moderate to severe epithelial dysplasia Unspecified laryngeal tumour Oropharyngeal carcinoma with laryngeal extention Vocal cord mass with leucoplakic patches Malignant goitre Inverted papilloma  Neurological RLN palsy post thyroidectomy Vc paresis secondary to motor neurone disease Vc paresis secondary to toxic goiter Unknown Causes  Socio-economic Burden Loss of working hours/income. Quality of life. Cost of management. Relevant anatomy Relevant anatomy Relevant anatomy  Physiology of the larynx: 1. Respiration. 2. Protection of the lower air passages. 3. Phonation (voice production) 4. Fixation of the chest.  Physiology of the larynx: 1. Respiration. 2. Protection of the lower air passages. 3. Phonation (voice production) 4. Fixation of the chest. Voice production Voice production Voice production Aetiopathogenesis of hoarseness Loss of approximation as seen in vocal paralysis, fixation or tumour coming in between Size of the vocal cords may increase in oedema of the cord or tumour, or may decrease in partial excision Stiffness, decreases in paralysis and increases in spasmodic dysphonia or fibrosis Aetiopathogenesis Vocal cord edema from; Voice abuse Acute laryngitis Allergy Upper respiratory tract infection Aetiopathogenesis Recurrent laryngeal nerve injury Aetiopathogenesis Vocal polyp/nodule Aetiopathogenesis Vocal polyp Aetiopathogenesis Chronic laryngitis  Fungal infection  TB laryngitis  Chronic rhinosinusitis Aetiopathogenesis Laryngeal cancer Trauma oBlunt oPenetrating oIatrogenic  Office pins Toys Earrings Beads Coins Battery Foreign bodies Laryngopharyngeal reflux Cigarette smoking and alcohol  Benign tumours o Papilloma (HPV) o Hemangioma o Chondroma o Leucoplakia Voice over-use Voice misuse  Management History Physical examination Investigation Treatment History Hoarseness lasting for more than 2 weeks Male >40 years Sudden onset of hoarseness. Associated difficulty breathing Weight loss Cigarette smoking/alcohol History Hoarseness (onset, duration, progression) Occupation (Voice abuse, voice overuse, voice misuse) Trauma / throat instrumentation Ingestion of corrosives. History Difficulty swallowing or painful swallowing and throat clearing Neck swelling Feeling of foreign body in the throat Heart burn or regurgitation Physical examination General examination Ear, nose and throat Indirect laryngoscopy – mirror, flexible fibre-optic laryngoscopy Neck Other systems: chest, abdomen, cardiovascular, musculoskeletal and neurological Indirect Laryngoscopy Flexible fibre-optic laryngoscopy Investigations Chest/neck X-ray CT scan MRI Barium swallow Video stroboscopy Direct Laryngoscopy & biopsy/Bronchoscopy/Esophagoscopy Thyroid function test Blood test; FBC, E,U&Cr TB screening  Investigations (Radiology) X-ray soft tissue neck  Investigations (Radiology) X-ray soft tissue neck Investigations (Radiology) Chest X-ray Investigations (Radiology) CT scan Investigations (Radiology) MRI Investigations Direct laryngoscopy and biopsy Investigations Video stroboscopy Investigations (Blood tests) Thyroid function test Full blood count Electrolyte, urea & creatinine Investigations (Tuberculosis) Treatment Treatment is multidisciplinary Treatment (Inflammatory) Laryngitis Treatment (Inflammatory) Laryngitis Hydration Treatment (Inflammatory) Laryngitis Treatment (Inflammatory) Chronic non-specific Laryngitis Antibiotics Analgesic Steroid Remove offending agent Treatment (Inflammatory) Chronic Specific Laryngitis Treat cause o Chronic rhinosinusitis. o Laryngo-pharyngeal reflux disease. o Chronic tonsillitis. o Tuberculous laryngitis. Reinke’s edema Conservative management o Quit smoking o Reflux management o Voice therapy Surgery Vocal polyp Surgical excision- primary treatment Vocal nodule Voice therapy Surgical excision; voice therapy fails/long-standing /large nodules Vocal fold granuloma Conservative treatment o Remove the inciting cause o Antireflux o Voice therapy Surgery Neuromuscular Conservative management o Neurotropic medications o Quarterly laryngoscopy Phonosurgery o Microlaryngoscopic surgery o Laryngeal injection technique o Laryngeal framework surgery o Nerve-muscle graft techniques o Reinnervation techniques Squamous papilloma Surgical excision. Voice rest afterwards. Malignant tumours Surgery Chemotherapy Radiotherapy Prevention Vocal hygiene Increase fluid intake Quit smoking Avoid alcohol Avoid/reduce spicy food Avoid throat clearing Avoid mouth-breathing Moderate voice loudness. Avoid exposure to irritants Recommendation Refer any patient with non-remitting hoarseness Recurrent hoarseness Use public address system when necessary Vocal hygiene Prompt treatment of upper respiratory tract infection Conclusion Hoarseness is a common complaint and has various causes many of which may be overlooked. However, it may be more than just a voice change. Hence the need for early presentation or referral of all patient with hoarseness to the ENT clinic. THANK YOU FOR LISTENING --- [1. The process of voice production involves the production of sound by the action of expired air on the vocal cords and modification by the pharynx, nose, mouth, tongue, lips and chest. Chevalier Jackson pointed the significance of hoarseness as a signal of distant malignancy and other conditions. Benign causes of hoarseness appear to be more common than malignant causes, but it is difficult to say whether the cause of a particular case of hoarseness is benign or malignant; this widespread belief that hoarseness is often due to a benign cause gives Voice over-use Goals To Understand the concept of hoarseness To outline common causes of hoarseness To enumerate the management of hoarseness To show the ENT, UITH experience To outline the Challenges in management in our environment