1. Regulate flow of air into our lungs 2. Protect airway from choking on material in the throat 3. Cough reflex 4. Voice production

- Unilateral, usually pedunculated - Smooth surfaces, regular edges, well-circumscribed - No necrosis or hemorrhage - Can be caused by overuse/ misuse of voice - Endolaryngeal microsurgery (ELMS) - Originates from stratified squamous non-keratinizing epithelium (first layer)

- HPV 6 and 11 - Always biopsy first TRO SqCC - Advise patient that it’s recurrent, so observe only unless obstructing airway

- Bilateral, symmetrical, smooth, well-circumscribed, hemispherical - Typical location is at junction of anterior 1/3 and posterior 2/3 of true vocal folds in superficial lamina propria

Hoarseness Flashcards by Amanda Sim

Function of larynx

Regulate flow of air into our lungs
Protect airway from choking on material in the throat
Cough reflex
Voice production

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Subsites of larynx

Supraglottis
Glottis
Subglottis

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Recurrent laryngeal nerve innervation

Sensory innervation to glottis and subglottis
Motor innervation to all internal muscles of larynx, except cricothyroid muscle

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Superior laryngeal nerve innervation

Internal branch provides sensory innervation to supraglottis
External branch provides motor innervation to cricothyroid muscle

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Function of cricothyroid muscle

Tenses vocal folds producing high-pitched sounds
- Supplied by external branch of superior laryngeal nerve

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Pathway of RLN

Loops around subclavian artery

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Pathway of LLN

Loops around arch of aorta

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Arterial supply to larynx

Superior laryngeal artery
- branch of superior thyroid artery (from ECA)

Inferior laryngeal artery
- branch of inferior thyroid artery (from thyrocervical trunk)

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Venous drainage of larynx

Superior laryngeal vein
-> superior thyroid -> IJV

Inferior laryngeal vein
-> inferior thyroid -> left brachiocephalic vein

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Common causes of hoarseness

Infection
- Infective Laryngitis (acute/chronic)
- Croup/acute laryngotracheobronchitis

Inflammatory
- Vocal cord nodules
- Vocal cord cysts
- Reinke’s edema

Neoplastic
Benign
- Vocal cord polyp
- Vocal cord papilloma

Malignant
- Larynx carcinoma

Others
- Vocal cord paralysis

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Management for acute/chronic infective laryngitis

Symptomatic
- voice rest
- hydration
- cough suppressants

+/- abx

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Causes of chronic infective laryngitis

Tuberculosis
Chronic sinusitis
Laryngopharyngeal reflux

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Clinical features of croup/acute laryngotracheobronchitis

Preceded by URTI symptoms

Then rapid progression:
Hoarseness of voice
Inspiratory stridor
Barking cough

*Symptoms are worse at night

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Vocal cord polyp

Unilateral, usually pedunculated
Smooth surfaces, regular edges, well-circumscribed
No necrosis or hemorrhage
Can be caused by overuse/ misuse of voice
Endolaryngeal microsurgery (ELMS)
Originates from stratified squamous non-keratinizing epithelium (first layer)

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Vocal cord papilloma

HPV 6 and 11
Always biopsy first TRO SqCC
Advise patient that it’s recurrent, so observe only unless obstructing airway

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Vocal cord nodule

Bilateral, symmetrical, smooth, well-circumscribed, hemispherical
Typical location is at junction of anterior 1/3 and posterior 2/3 of true vocal folds in superficial lamina propria

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Causes of vocal cord nodules

Found in singers and teachers
A/w voice abuse/ chronic voice strain, heavy smoking

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How does vocal cord nodules form?

Chronic friction of vocal cords on each other –> callus formation –> Vocal cord nodules
Early nodules are soft and 2° to submucosal hemorrhage while mature nodules are firm and due to fibrosis
Thickened epithelium over matrix of fibrin and collagen

Management of vocal cord nodules

Voice rest
Hydration
Learn proper vocal hygiene
Speech therapy
Tx underlying causes (E.g., cough, reflux, stop smoking, shouting, prolonged conversations)

Vocal cord cyst

In superficial lamina propria
ELMS
affects one layer deeper than vocal cord polyps

Reinke’s edema

Fluid in Reinke’s space causing swelling of vocal cords
- Voice quality is rough and low pitch

“2 bags of water”

Causes of Reinke’s edema

Smoking
LPR
Hypothyroidism (Due to myxedema)

Suspect vocal cord paralysis in patients presenting with

Hoarseness &
Cough whenever eating/drinking ie aspiration risk

Causes of unilateral vocal cord paralysis

Iatrogenic
- Thyroidectomy
- CABG
- C-spine Sx
- Esophageal Sx
- Intubation causing traction and stretching

Neoplastic
- Lung CA (Pancoast tumour)
- Thyroid CA (Commoner)
- Esophageal CA

Trauma
- Blunt injury
- Deep neck lacerations

Neurological
- Posterior circulation stroke
- Multiple sclerosis

Neuromuscular
- GBS
- Myasthenia gravis

Idiopathic

Most pertinent investigation to send for vocal cord paralysis

CT scan from base of skull to thorax TRO malignancy

Management of vocal cord paralysis

1. Type 1 thyroplasty: implant 2. Injection medialisation of vocal cords *paralyzed vocal fold (vocal cord) is pushed to the middle so that the functioning vocal fold can close properly

What do the positions of the paralysed vocal cords indicate?

Lateral: Poor voice but good airway Medial: Good voice but poor airway

Laryngeal carcinoma is mostly what type of carcinoma?

Squamous cell carcinoma

Risk factors for laryngeal Ca

1. smoke 2. alcohol 3. reflux 4. paint 5. hpv

Hoarseness >3 weeks in duration

Refer ENT TRO malignancy

Symptoms of laryngeal ca

1. Chronic hoarseness 2. Cough 3. Neck lump 4. Globus feeling 5. Throat irritation 6. Blood stained sputum

Treatment of laryngeal Ca

Histological confirmation via biopsy Stage: CT larynx & thorax Surgical: - Trans-oral laser resection - Open surgery -> Partial laryngectomy -> Total laryngectomy Non Surgical - Radiation - Chemo-radiation

Speech rehabilitation options post-larynectomy/for laryngeal speech

Esophageal speech Electrolarynx Transesophageal puncture and voice prosthesis

What scale is used to assess hoarseness?

GRBAS Subjective grading from 0-3 Roughness (Irregularity of vibration) Breathiness (Air leakage) Asthenia (Weakness) Strain (Muscle tension)

Gold standard examination for hoarseness

Strobovideolaryngoscopy

What is VHI 10?

Video handicap index - Self-rating questionnaire that determines impact of perceived vocal abnormality on day to day life of patient - 10 items - Grade 0-4 - VHI score >11 is considered abnormal

Extrinsic muscle of larynx

Cricothyroid

Intrinsic muscle of larynx

Adductors: Thyroarytenoid: Adductor Portion Lateral Cricoarytenoid Interarytenoid Transverse Arytenoid Abductor: Posterior cricoarytenoid

Causative organism of croup

Viral infection (most commonly parainfluenza virus)

Age of incidence for croup

6 months - 3 years old

Symptoms of croup are worse when?

At night

Secondary bacterial superinfection in croup can be caused by

Staph Aureus (give abx)

What sign can be observed in anterior neck xray for croup?

Steeple sign (Subglottic tracheal narrowing mimics shape of church steeple)

Management of croup

- Anti-pyretics - Mist Tx - Avoid smoking at home -Humidified air, oxygen If severe - IV fluids - Oral dexamethasone to reduce airway swelling (IV too) - Nebulized adrenaline - Intubation