Hoarseness

Question 1

Probability diagnosis

Answer 1

• Viral URTI: acute laryngitis
• Non-specific irritative laryngitis (Reinke oedema)
• Vocal abuse (shouting, screaming, etc.)
• Smoking
• Nodules and polyps of cords
• Presbyphonia in elderly: ‘tired’ voice
• Hypothyroidism
• Acute tonsillitis
• intubation
• oesophageal reflux

Chronic:

• children—‘screamer’s nodules’
• adults—non-specific laryngitis e.g. smoking; ‘barmaid’ syndrome

Question 2

Serious disorders not to be missed

Answer 2

Cancer:

• larynx
• lung
• including recurrent laryngeal nerve palsy
• oesophagus
• thyroid

Imminent airway obstruction (e.g. acute epiglottis, croup)

Rare other severe infections (e.g. TB, diphtheria)

Foreign body

Motor neurone disease

Myasthenia gravis

Question 3

Pitfalls (often missed)

Exclude: imminent airway obstruction (e.g. croup, epiglottitis, malignancy, hypothyroidism), other severe infections (e.g. diphtheria, TB), foreign body, allergy, goitre.

Also uncommon disorders Vocal Cord Dysfunction Syndrome and Excessive Dynamic Airways Collapse (‘floppy trachea’), both of which can mimic asthma.

Answer 3

1. Toxic fumes
2. Vocal abuse
3. Benign tumours of vocal cords, e.g.

• Polyps
• ‘singer’s nodules’
• papillomas

1. Gastro-oesophageal reflux → pharyngolaryngitis
2. Goitre
3. Dystonia
4. Physical trauma (e.g. post-intubation), haematoma
5. Fungal infections. e.g.

• Candida with steroid inhalation
• immunocompromised

1. Allergy (e.g. angioedema)
2. Leucoplakia
3. Systemic autoimmune disorders, e.g.

• SLE
• Wegener granulomatosis)

Question 4

Masquerades

Answer 4

drugs:

• antipsychotics
• anabolic steroids

smoking → non-specific laryngitis

hypothyroidism

acromegaly

Question 5

Is the patient trying to tell me something?

Answer 5

Consider:

functional aphonia

functional stridor

Question 6

Key history

Answer 6

Note the nature and duration of the voice change.

Enquire about;

• corticosteroid inhalation
• excessive or unaccustomed voice straining, especially singing,
• recent surgery
• possible reflux
• smoking or exposure to environmental pollutants.

Elicit associated respiratory or general symptoms such as cough and weight loss.

Question 7

Key examination

Answer 7

Palpate the neck for enlargement of the thyroid gland or cervical nodes

Perform a simple oropharyngeal examination except if epiglottitis is suspected

Check for signs of hypothyroidism, such as

• coarse dry hair and skin
• slow pulse
• mental slowing

Perform indirect laryngoscopy if skilled in the procedure

Question 8

Key investigations

Answer 8

Thyroid function tests

CXR if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy

Indirect laryngoscopy (the gag reflex may preclude this)

Direct laryngoscopy

a special CT scan to detect suspected neoplasia or laryngeal trauma.

Question 9

Diagnostic tips

Answer 9

Larynx must be visualised.

Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases are often cause for concern.

Remember that intubation causes transient hoarseness.

Consider GORD in the elderly.

Question 10

Exclude:

Answer 10

Imminent airway obstruction e.g.

• croup
• epiglottitis
• malignancy
• hypothyroidism

Other severe infections (e.g. diphtheria, TB)

Foreign body

Allergy

Goitre.

Also uncommon disorders:

Vocal Cord Dysfunction Syndrome and

Excessive Dynamic Airways Collapse (‘floppy trachea’)

• both of which can mimic asthma.

Question 11

Management

Answer 11

Acute:

• treat according to cause
• vocal rest or minimal usage at normal conversation
• avoid irritants (e.g. dust, tobacco, alcohol)
• consider inhalations and cough suppressants

Chronic:

• establish diagnosis
• consider specialist ENT referral