Voice disorders Flashcards
What are the main function of the larynx?
Acts as a sphincter to prevent things getting into the lungs.
Speech
Allows cough
What does the larynx connect to superiorly and inferiorly?
Superiorly it connects to the pharynx
Inferiorly the trachea
What does the larynx consist of?
Thyroid cartilage
Cricoid cartilage
The epiglottis
The arytenoid cartilages
What does the epiglottis attach to?
The thyroid cartilages
What are the arches called that food bolus falls down to enter the oseophagus?
pyriform fossa
What are the glottis?
It is another name for the vocal cords
What is the most common malignant tumour of the larynx?
a squamous cell carcinoma
What risk factor has the highest association for tumour of the larynx?
(which is the second)
as the most common malignant tumour is a squamous cell carcinoma, the commonest risk factor is unsurprisingly:
Smoking
(also heavy alcohol intake)
What is the primary symptoms of carcinoma of the vocal cords?
Hoarseness
What is the prognosis of carcinoma of the vocal cords and why?
95% 5-year survival
As a small lesion will cause symptoms early AND
the area has poor lymphatic drainage
How long should hoarseness persist for before you should suspect cancer?
6 weeks
How is the larynx split into the supraglottis and subglottis?
It is divided by the vocal cords
What is the prognosis of cancers in the supraglottis and subglottis?
not as good as for vocal cord tumours as they have less specific symptoms
What are the symptoms of cancers in the supraglottis and subglottis?
Throat irritation
Cough
Referred otalgia
Lump (Lymph node in the neck)
What are the signs of cancers of the larynx?
leukoplakia
narrowing of airway
Fixation of vocal cords
What are the treatment options for laryngeal malignancies?
endoscopic removal
radiotherapy
radical surgical excision (if radical enough tracheostomy will be required)
From what nerve does the recurrant laryngeal nerve come from?
The vagus nerve
What structures do the left and right recurrant laryngeal nerves loop under?
Left - runs under arch of aorta
Right - under the right subclavian artery
Explain the rule of thumb for vocal cord palsies.
1/3 due to surgery
1/3 idiopathic
1/3 neoplastic
To what degree to vocal cord palsies affect the left and right sides?
75% Left
15% Right
10% Bilaterally
What is the most common malignant cause of vocal cord palsies?
Cancer of the bronchus
What are the symptoms of a recurrant laryngeal nerve palsy?
Horseness which tires with talking
choking with fluids
diplophonia (the voice simultaneously produces two sounds of different pitch)
weak bovine cough
High pitched voice
What is the Ix strategy for vocal cord palsies?
Assume malignant until proven otherwise
X-ray is mandatory
CT if nothing seen on x-ray
Other than surgical trauma and neoplasia what can cause vocal cord palsy?
crico-arytenoid joint may become fixed due to
severe RA or
reflux
What is muscle tension dysphonia?
Normal hoarse voice
What are the causes of muscle tension dysphonia?
1ry causes: stress, axiety, vocal abuse, etc, etc
2ry causes: e.g.
excessive tension required to
overcome a deficiency in the voice producing mechanism
caused by e.g. cord structural defect
How does muscle tension dysphonia present?
variable hoarseness
can range from normal to no voice BUT worsens with use
dryness/uncomfortable sensation in the throat
What is the treatment for muscle tension dysphonia?
remove causative factor
general lifestyle advice
What are the types of vocal cord benign lesion?
papillomata nodules polyps cysts Reinke’s oedema
What are the most common benign vocal cord lesion?
Papillomata of the larynx
In whom are papillomata of the larynx most commonly seen?
Children, but can manifest in adults
What causes papillomata of the larynx?
HPV
How severe is papillomata of the larynx?
It varies from very minor to affecting the whole respiratory tree.
What is the most common site of papillomata of the larynx? (and hence how does it present)
The vocal cords (presents with hoarse voice)
In severe cases how will papillomata of the larynx present?
with stidor
How is papillomata of the larynx treated?
laser. several session over several years if often require due to the rapidly recurring nature
Immune regulation with
steroids
or interferon can also be used
In adults histology to check for squamous cell carcinoma transformation
What are vocal cord nodules caused by (and hence what are other names used for it?)
Result from vocal abuse (singers or screamer’s nodules)
What symptoms do vocal cord nodules cause?
Hoarseness and
gruffness of the voice
What is the treatment for vocal cord nodules?
Nothing unless pt is not happy with voice
Speech therapy (fairly successful)
Surgical excision
What is the appearance of vocal cord nodules?
Small
White
Thickenings of the vocal cords BILATERALLY
How do vocal cord nodules form?
Small haemorrhage due to trauma (so are soft)
Eventually fibrose (are firm)
What is Reinke’s oedema?
Inflammation of the vocal cords
leads to odema along the whole length of
Reinke’s space
What causes vocal cord polyps and cysts?
When inflammation of the vocal cords along Reinke’s space (this is Reinke’s oedema) is localised to one area rather than the whole cord as in Reinke’s oedema.
The resulting oedema in Reinke’s space causes a polyp or cyst
What specifically causes a vocal cord cyst?
When the localised oedema under the covering of the cord remains contained within it
What specifically causes a vocal cord polyp?
results from oedema which is superficial within the cords prolapsing into the airway.
What is the Ix for vocal cord cysts and polyps?
Removal for histology
What is the main presenting compaint for vocal cord polyps and cysts?
Hoarse voice
What are the main causes of vocal cord polyps?
Shouting when you have a cold
extraoesophageal reflux
Who typically get vocal cord polyps?
Men
40y/o
What are the main symptoms of vocal cord polyps?
Hoarse voice
Voice cutting out when speaking
What does a vocal cord polyp look like?
unilateral
grey or haemorrhagic
swelling
arising in the middle of the cord
What is the treatment for vocal cord polyps?
Medical:
i.e. treatment for extraoesophageal reflux or steroids
Surgical removal
Voice therapy
What are the causes of Reinke’s oedema?
Smoking
Overtalking
Reflux
What are the symptoms of Reinke’s oedema?
Deep gravelly voice
If severe: choking
What does Reinke’s oedema look like?
bilateral
grey or erythematous
swelling
along the whole length
What is the treatment for Reinke’s oedema?
Stop smoking
Surgical reduction
Medical treatment for: reflux and voice therapy
Which gender does Reinke’s oedema occur more in?
M=F
Which gender do vocal cord cysts occur more in?
M=F
What are the causes of vocal cord cysts?
It is not known
What are the symptoms of vocal cord cysts?
Hoarse voice
Pitch breaks
Loss of range of voice
Increased effort to speak
What is the treatment for vocal cord cysts?
stop smoking
surgical reduction
medical treatment for reflux and voice therapy
What are the causes of reduced/absent vocal cord mobility?
laryngitis
cancers (benign or malignant) of the cord/joint or a tumour of the nerve
damage from intubation
laryngeal reflux
functional dysphonia
What will be the result if the vocal cords cannot close fully?
The voice will be affected
The airway will not
What will be the result if the vocal cords cannot open fully?
The voice will NOT be affected
The airway will be affected
What is functional dysphonia?
Poor voice quality without any obvious
anatomical,
neurological
or other organic difficulties
affecting the larynx (aka voice box)
What are some potential causes of functional dysphonia?
bereavement
Psychiatric causes
Give some examples of treatment for functional dysphonia?
Reassurance it will resolve
Speech therapy can reduce tension
Psych referal
What are the symptoms of functional dysphonia?
Hoarse voice
which is weak and tires easily
What are potential causes of acute laryngitis?
As part of a general infective process (post-URTI, HPV, candida -> poor inhaler technique)
In isolation it can be due to:
vocal abuse
irritants such as cigarette smoke
What are the symptoms of acute laryngitis?
Hoarse voice (can lead to complete aphonia)
pain on speaking + swollowing
How do the vocal cords appear in acute laryngitis?
Erythematous
Odematous
Including the whole larynx
How is the vocal cord movement affected in acute laryngitis?
It is restricted
symmetrically
not completely paralysed
How is acute laryngitis treated?
Mainly supportive:
Steam inhalation
Voice rest
Can also use:
cough suppressants
What is the risk if you abuse your voice during acute laryngitis?
lead to hemorrhage within the larynx leading to
fibrosis
and thus permanent vocal disorders
How dangerous is epiglottis?
Can be life threatening
When should you always consider epiglottitis?
In children (as it is more common) with
pyrexia and
sore throat
How may epiglottitis unfold in a child?
Signs of an URTI
leading to complete airway obstruction
What should you avoid doing in a patient with epiglottitis?
Lying them down as this may collapse the airway
Doing intra-oral investigations without intubation or emergency tracheostomy
What is the common responsible agent of epiglottitis?
H.influenzae
What is the treatment for epiglottitis?
IV antibiotics (as the usual causative factor is H.influenzae)
What is usually the cause of croup?
Viral infection
What is croup also known as?
laryngotracheobronchitis
How does croup compare to epiglottitis?
It can also be fatal
Croup has a slightly longer course
How does croup present?
low grade URTI
then pyrexia
and stidor
There will be generalised deterioration of the child
What is the treatment for croup?
IV antibiotics
nebulised adrenaline
Ventilation if severe
What is the cause of chronic laryngitis?
Multifactorial cause but most important one is:
smoking
What will be the classic Hx of chronic laryngitis?
a nasty URTI
and since this they have been hoarse
Why does the inflammation in chronic laryngitis remain?
Due to multiple factors such as:
vocal abuse
sinusitis leading to post nasal drip
acid reflux
What are the symptoms of chronic laryngitis?
hoarse voice
What will examination of the vocal cords in chronic laryngitis show?
erythematous cords which may be
thickened and
oedematous
What are the risks associated with chronic laryngitis?
The chronic inflammation can lead to:
dysplasia
and carcinoma in situ
What is the Mx of chronic laryngitis? (mention when surgery is indicated)
intensive speech therapy
removal of causitive factors
(surgery is no longer used except for diagnostic purposes)
What is dysphonia?
any impairment
in the voice or
difficulty speaking
What is dysarthria?
Imperfect articulation of speech due to disturbances of muscular control or incoordination
What is dysphasia? (which specific situations is this term used)
Impairment in the:
production
and
comprehension
of speech
(particularly when related to a brain injury)
What is sensory dysphasia?
Impairment in the COMPREHENSION of speech
What is expressive dysphasia?
Impairment in the PRODUCTION of speech
How can listening to the voice help you determine the origin of a voice problem?
If rough then a problem with the way the cords are vibrating
if breathy then implies vocal cord palsy (i.e. they cannot be completely brought together)
Name the potential causes of voice disorders?
Think C then LMNOP
CARCINOMA
cysts
cord palsy
Laryngitis Muscle tension dysphonia Nodules Oedema (Reinke's) Polyps Papillomatosis
How long do surgeons generally wait before operating on vocal cord issues?
6 months as function may return
What is the common infective agent in tonsillitis?
Viral
What are the symptoms of tonsillitis?
Malaise, pyrexia
sore throat
white/yellow slough on tonsils
What is the treatment for tonsillitis?
Hydration and analgesia
Surgery if >4 cases per annum
How do the size of adenoids change as you get older?
They regress with age
Why would an adenoidectomy be performed?
Sleep apnoea/snoring
Recurrant glue ear (as the adenoids are a bacterial resevoir)
