Hoarseness

Question 1

Which is the only correct statement regarding the innervation of the larynx?

A. All the muscles of the larynx are supplied by the recurrent laryngeal nerve (RLN).
B. The right RLN hooks around the arch of the aorta.
C. All the muscles of the larynx are supplied by the RLN except cricothyroid muscle.
D. Damage to the left RLN is a common complication of thyroid surgery.
E. Sensory innervation to the supraglottis (above the vocal cords) is provided by the RLN.

Answer 1

C is correct

Question 2

What does hoarseness mean?

What is the main cause?

Rx?

Answer 2

difficulty producing sound with change in voice pitch or quality (breathy, scratchy etc)

URTI

Self-limiting

Question 3

When should hoarseness be investigated further?

What are some common causes of a hoarseness

Answer 3

If it has lasted longer than 3 wks as the biggest presentation of laryngeal cancer

GORD
Dysphagia 
Smoking 
Stress 
Singing and shouting

Question 4

1 investigation for hoarseness

Answer 4

Laryngoscopy

Question 5

Differentials:

Laryngeal cancer - what sort of presentation will patients have?

Vocal cord palsy - what sort of presentation will patients have?

Answer 5

Progressive and persistent gruff voice

Weak breathy voice - usually due to cancer

Question 6

Differentials:

Reflex laryngitis - what is it?

Answer 6

PR stands for laryngopharyngeal reflux.

The term reflux describes the backward or return flow of stomach acid.

Reflux is often associated with heartburn, the result of stomach acid irritating the throat.

In LPR, stomach acid flows not only back up to the esophagus (food pipe) but also further up to the throat

Question 7

Differentials:

Reinke’s oedema - what is it?

Answer 7

swelling of the vocal cords due to fluid (edema) collected within the Reinke’s space.

Usually happens in women who smoke and overuse their voice

Question 8

Differentials:

Vocal cord nodules:

• Cause
• Rx

Answer 8

Vocal abuse (Poor singing technique, shouting, voice abuse)

Speech therapy
Excision

Question 9

Red flags symptoms to ask for?

Answer 9

Does he have a persistent sore throat/odynophagia?
Does he have persistent dysphagia?
Does he have persistent unilateral otalgia?
Does he have a persistent cough/shortness of breath or haemoptysis?
Has he lost weight?

Question 10

Differentials:

Benign vocal cord lesions:

4 different types

Which ones are managed with speech therapy and which ones are surgically excised?

Answer 10

Nodules are managed with voice hygiene and speech therapy is key.

Cyst/polyps are managed by surgical excision (and biopsy to exclude malignancy).

Question 11

Differentials:

Vocal cord paralysis:

• What do you get dysphonia?
• What is the cause?
• Why do you get a weak voice with it?
• What can be done to manage this?

Answer 11

Incomplete cord closure will result in dysphonia and may also result in aspiration.

Unilateral palsy is the most common and the nerve damage can be anywhere along the course of the vagus nerve from the brainstem to the neck.

The affected cord lies in a medialised position (paramedian) and therefore the contralateral working vocal cord needs to stretch beyond the midline to give good voice production. This leads to a weak voice.

Sometimes vocal cord medialisation procedures are undertaken to allow the contralateral side to meet the affected side more efficiently.

Question 12

Differentials:

Functional dysphonia

JUST READ IT - MAKES MORE SENSE

Answer 12

The commonest cause of dysphonia accounting for approximately 30% of patients presenting with altered voice.
Refers to a voice problem in the presence of a normal larynx.
People in occupations where voice use is central ie teachers, call centre staff are more at risk of developing functional dysphonia.
Often called “muscle tension dysphonia” it is thought that altered laryngeal muscle tension results in an altered voice.