SPC- Hoarsenss (Dysphonia) Flashcards
Be able to recall the definition of hoarseness Describe some of the causes of hoarseness
What is hoarseness?
Difficulty producing sounds, with change in voice pitch or quality (scratchy, breathy, husky)
What are the majority of cases of hoarse voice caused by?
Upper respiratory tract infections that are self limiting Voice overuse (singing and shouting) is also a common cause
If present, what factors would suggest further investigation for the cause of hoarseness?
Hoarseness lasting> 3 weeks (Especially in smokers- as it is the main and often only presentation of laryngeal carcinoma )
Neck lump
Any red flags for malignancy
If patient presents with hoarseness what other things should you ask them about?
Smoking history Family history of cancer GORD Dysphagia- Suggesting neck lump? Stress Singing Shouting Viral Illness features (most are caused by URTI) Coughing up any blood
If further investigation is required, what test would be requested?
Laryngoscopy
Assessment of cord mobility, inspect the mucosa and exclude local causes
A flexible laryngoscope can be used- entering through the nasal cavity
What are the differential diagnoses for hoarse voice?
Laryngeal cancer Vocal cord/Laryngeal Nerve palsy Laryngitis (Most common) Reflux Laryngitis (Ask about GORD) Reinke's Oedema Vocal Cord Nodules (Caused by vocal abuse) Spasmodic Dysphonia Muscle Tension Dysphonia Children with functional speech disorders
What is the most common cause of acute laryngitis?
Viral URTI that is usually self limiting-
e.g. Rhinovirus, coronavirus, influenza virus, respiratory syncytial virus (RSV)
There may be secondary infection with Strep or Staph
What other factors can cause laryngitis?
Reflux laryngitis due to GORD
Auto-immune disease (e.g. RA)
What are the symptoms of laryngitis?
Pain
Felt Hypopharyngeal- last part of the pharynx where the larynx and the oesophagus meet
Dysphagia
Pain on phonation
Hoarse voice- oedema of vocal cords causes this
Preceding features of viral illness- Fever, fatigue, headache, nausea…
If malignant cause consider red flags for this
What is the treatment for acute laryngitis?
Often self limiting
Supportive treatment if viral infection suspected- simple analgesia, fluids, steam inhalations
Bacterial cause- Abx (Phenoxymethylpenicillin 500mg/6h PO for 1 week)
What is chronic laryngitis?
Long term inflammation of the vocal cords leading to chronic changes
Associated with smoking and pollution/occupation exposure
(Creating chronic inflammation of the larynx- associated with oedema and vocal cord polyps)
What is the treatment for chronic laryngitis?
Drainage of oedema if present Excision of any nodules Voice rest Speech therapy Avoidance of pollutants Smoking cessation
What is reflux laryngitis?
Reflux of gastric contents causes irritation of the vocal cords- this can lead to chronic laryngitis
History of GORD- Retrosternal burning pain, unpleasant taste in mouth, bad breath
~15% of all visits to ENT clinics are due to reflux laryngitis
How is reflux laryngitis treated?
PPIs- e.g. Omeprazole, lansoprazole
Diet/Lifestyle Modification
Weight loss
Surgical Fundoplication- if above fail, top of stomach wrapped around LOS
What is Reinke’s Oedema?
Swelling of the vocal cords due to fluid collecting within Reinke’s Space (this is a gelatinous layer of the vocal cords underneath the other cells)
Vocal cords have a sac like appearance
What causes Reinke’s Oedema?
Chronic laryngitis- chord irritation from smoking/chronic vocal cord abuse
Symptoms are therefore similar to laryngitis
Described as a deep gruff voice- women often say they sound like a man
What patients is Reinke’s Oedema almost exclusively seen in?
Smoking (Main cause)
Women
Hypothyroids
Elderly
What is the treatment for Reinke’s Oedema?
Reduce the risk factors- stop smoking, GORD management, prevent over use of vocal cords
SALT therapy
If conservative treatment fails surgical treatment can be considered- microlaryngoscopy to treat oedema. CO2 laser can be used to make the small incisions (laser therapy)
What are vocal cord nodules?
Nodules that develop due to trauma/chronic inflammation of the vocal cords
Fibrous tissue can develop causing the affected area to be stiffer and the vocal cords cannot vibrate effectively
Appear in pairs due to trauma occurring to the vocal cords when coming into contact
Note- Form at the junction of the anterior 1/3 and posterior 2/3 of the cord. This is the middle of the membranous vocal fold as the posterior 1/3 is cartilage
What kind of people might vocal cord nodules be seen in?
Teachers Singers Presenters Angry people Football fans Think of vocal cord overuse
What voice change is seen with vocal cord nodules?
Cause hoarse voice as the cords cannot come into contact as usual
Variable husky voice
What is the treatment for vocal cord nodules?
Speech therapy- prevent further injury and allow for tissue repair. Encourages good vocal habits, warn-ups, hydration, rest time
Failure of this surgical excision may be considered
What is muscle tension dysphonia?
Functional disorder due to abnormal laryngeal muscle tension
Excessive effort is used to produce voice
Patients complain of a husky hoarse voice that tires easily
Voice is often best in the mornings and deteriorates with use
What is muscle tension dysphonia associated with?
Previous episode of laryngitis- particularly in patients who have had to carry on with heavy voice use despite dysphonia
Professional voice users
Voice overuse
Psychological stress
