Specialist ENT HOARSENESS OF VOICE

HOARSENESS OF VOICE

Introduction

Hoarseness is a symptom and not a disease. It is a general term that describes an abnormal voice. When hoarse, the voice may sound breathy, raspy, strained or there may be changes in volume (loudness) or pitch (how high or low the voice is). The changes in sound are usually due to disorders related to the vocal folds, which are the sound- producing parts of the voice box (larynx). There are many causes of hoarseness most are not serious and tend to go away in a short period of time. While not always the case, persistent hoarseness can be a warning sign of benign or malignant laryngeal disease.

Aetiology:

I. Congenital:

a) Laryngeal web

  • Laryngeal web is a congenital condition where there is failure of resorption of tissue between the vocal folds, causing varying degrees of airway obstruction. 
  • The condition may present at birth or in infancy with respiratory distress, stridor, and an unusual, weak, or absent cry.
  • If obstruction is severe, it can be life-threatening and requires emergency tracheotomy after birth. Milder cases may present later in life with hoarseness, stridor, wheezing, or dyspnoea. 
  • Laryngeal webs may be operated by cold steel or lCo2 laser .
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b) Laryngeal cysts

  • Laryngeal cysts commonly involve the supraglottic region,such as epiglottis and vallecula. Usually, they do not extend to the thyroid cartilage. Hoarseness of voice is the most common presenting symptom. 
  • They can be congenital or may develop eventually due to degenerative causes and often interfere with phonation. 
  • Treatment can be medical or surgical. Laser endoscopic surgery is often preferred. 
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II. Acquired:

c) Neoplastic.

  1. Benign:
    • Pharyngeal diverticula: Over flow of contents into larynx causes chronic irritation of the larynx and laryngitis.
    • Juvenile Laryngeal Papillomatosis.
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a) Haemangioma

  • Laryngeal haemangiomas are relatively rare and occur in two main forms–infantile and adult haemangiomas. 
  • While infantile haemangiomas are usually found to occur in the subglottis, adult haemangiomas occur commonly in the supraglottic regions of the larynx.
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b) Polyps and Cysts of vocal cords

  • Vocal fold polyps are benign lesions that are generally unilateral. Their shape can be sessile or pedunculated and contain gelatinous or translucent fluid. They can be fibrous, angiomatous or haemorrhagic.
  • The origin of the vocal polyp is phonotraumatic. Other  predisposing factors are gastroesophageal reflux, smoking and aspiration of aggressive chemical substances.
  • The main signs and symptoms are hoarseness or breathiness and vocal fatigue.
  • Treatment includes surgical excision of polyp in most cases followed by  voice rest, speech therapy and steam inhalation.
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  • Vocal fold cysts (also known as vocal cord cysts) are benign masses of the membranous vocal folds. These cysts are enclosed sac-like structures that are typically of a yellow or white colour. They occur unilaterally on the midpoint of the medial edge of the vocal folds.
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2. Malignant:

  1. Bronchial Carcinoma: This malignancy commonly involves the mediastinum and obstructs the superior vena cava causing recurrent laryngeal nerve palsy.
  2. Carcinoma of vocal cords and larynx.
  3. Thyroid carcinoma.
  4. Oesophageal malignancies involving the recurrent laryngeal nerve.

b)  Inflammatory:

  1. Acute laryngitis.
  2. Chronic laryngitis.
  3. Atrophic laryngitis: It is a rare condition characterized by atrophic changes in the respiratory mucosa with mucous producing glands.
  4. Tuberculosis.
  5. Singer’s nodules.
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6. Diphtheria.

7. Leprosy.

h) Traumatic:

  1. Intubation trauma.
  2. Inhalation of foreign body.
  3. Accidents.
  4. Strangulation.

e) Miscellaneous:

  1. Vocal cord palsy.
  2. Laryngeal oedema.
  3. Gout.
  4. Laryngocele.
  5. Functional aphonia.
  6. Reflux Oesophagitis.

Investigations:

    1. Blood: Routine blood investigations.
    2. Test for diabetes, syphilis (VDRL).
    3. Thyroid function tests.
    4. Indirect laryngoscopy in OPD.
    5. Direct laryngoscopy to confirm findings.
    6. Stroboscopy– Stroboscopy is a special method of examination of a vibration of vocal folds. A bright flashing light lasting a fraction of a second (10µs) is used to illuminate the vocal folds. This flash ‘freezes’ the movement of the vibrating vocal folds. By taking multiple snapshots at different phases of the vibratory cycle it is possible to see details of the change in shape of pliable surface of the vocal folds (i.e. the mucosa) with time.
    7. Fibre-optic laryngoscopy helps to check the larynx closely.
    8. Panendoscopy.
    9. CT Scan may be useful in cases of malignancy, lymphadenopathy and lesions involving the recurrent laryngeal nerve.
    10. Allergy Test.
    11. Voice analysis by a voice therapist gives a perfect picture of the voice quality.

Treatment of hoarseness of voice:

  1. History: To know of any trauma, onset and progress of the hoarseness.
  2. ENT examination to know the cause of the hoarseness.
  3. Treatment of the specific cause by medical or surgical options.
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