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Voice Disorders and Hoarseness

The main categories hoarseness are the organic categories, psychogenic and the unknown causes. Congenital causes include inflammatory neoplastic endocrines, such as hypothyroidism and trauma. Neurologic causes, psychogenic and unknown causes are associated with hoarseness. When you talk to a patient one of the things you need to ask about is the time course. How long has it been present. If the hoarseness has been present for more than a couple of weeks, you need to be a little more concerned about it. I don't get too concerned about somebody whoís been hoarse for a week or has a coexisting URI, but the patient you need to worry about is voice disorders, hoarseness, hoarse, vocal cord paralysis 

Especially if itís an older patient and a smoker, then you are obviously worried about cancer. I ask, "When is the hoarseness worse? Is it worse in the morning? Does it get worse as the day goes on? Does it get worse the more you use your voice?" Patients who have reflux often will have hoarseness worse in the morning when they first wake up. Theyíll have lots of throat-clearing. Patients who have voice abuse and other problems tend to get worse as the day goes on. I ask them to describe what their voice is like and I try to characterize their voice. Is it a rough voice? Is it soft? Is it breathy? Is there a change in pitch? In singers, is if a change in their range? Is it something they canít do that they previously could do? I ask about their voice use. Whatís their occupation? Are they a coach? Are they a salesperson? Do they have a lot of little kids? Do they end up doing a lot of yelling? Are they a teacher? Do they have a class with a lot of unruly kids where they end up doing a lot of crowd control? Coaching, singing, other extracurricular activities? Things like, do they hang out in bars? Bars are bad for the voice because of

Smoking, obviously, can cause a lot of problems like laryngitis and it can also cause squamous cell cancer of the larynx and various chemical toxicities. Sometimes Iíll get patients that are irritated by some chemical they work around. History. Things I always ask about, do they have rhinitis or sinusitis that could be aggravating their voice problems by the postnasal drainage dripping down, and irritating the vocal cords. Do they have allergies? Ask about endocrine problems, especially hypothyroidism.

Reflux is something that I see commonly all the time. Patients who have bad reflux and end up getting a laryngitis because the acid comes back up and bathes the larynx, especially at night. Thatís why they wake up in the morning and they are very hoarse in the morning. They do lots of throat clearing and are more hoarse in the morning. I ask about pulmonary problems. Do they have a chronic cough? Do they do a lot of throat clearing? Obviously trauma is going to be pretty self-evident. You try to get a little

Physical exam, other than just the mechanics of looking at the larynx, I try to get my own little view of their psychological status. Sometimes Iím lucky because I run a voice clinic and I have a speech pathologist with me and sometimes Iíll leave her alone with the patient for 15 or 20 minutes and she can find out all kinds of things about these patients, and sheís very empathetic. She comes and she tells me all kinds of things. All these personal problems these people have. They just open up to her and tell her everything. Itís really interesting. I look at adjacent areas, assess the thyroid for any nodules. Look for neck masses. Listen to lungs, if

Different ways to look at the larynx. How many of you know how to use an indirect mirror? Or feel comfortable using an indirect mirror? Maybe a fourth of the

Vocal cord paralysis is something you might see occasionally in your practice. The causes can be idiopathic, which is usually - itís never been proved - but probably due to a viral type insult to the recurrent laryngeal nerve. It can be iatrogenic, which is probably one of the most common causes, usually from thyroidectomy. When I evaluate a patient - first of all, when I have a patient who is like say 50-years-old, a smoker, who comes in who is suddenly hoarse and

You can also have bilateral vocal cord paralysis. The most common cause of bilateral vocal cord paralysis is thyroidectomy.

Hoarseness in children. The vast majority of children that you are going to see that are hoarse is either due to a URI or sinusitis or something like that. Or itís going to be screamerís nodules. Other things that you might see, hemangioma, subglottic stenosis, cysts, papillomas, laryngeal web. Iím going to go over some of these things. This just shows laryngeal vocal cord nodules. Also known as screamers nodules. These usually happen in little kids. They usually have a characteristically rough, sort of raspy voice. They have - what we call - a hard glottal attack. Their voice is sort of aggressive, they are loud. They are usually

Cutaneous hemangiomas. If they have stridor or they were hoarse, you would have to be suspicious for a subglottic hemangioma, which sometimes goes along. This shows a large hemangioma involving the larynx. All this red area. This is subglottic stenosis. This is the left vocal cord, right vocal cord and this is stenosis. This can be either acquired or congenital and the acquired type of subglottic stenosis is usually due to intubation. This shows a large subglottic cyst, left vocal

Next, Iím going to talk about adult lesions. Go through some of these different things you might see. This is probably what I have right now. This is acute laryngitis. It just shows red vocal cords, little bit swollen, little bit red. Usually due to a URI. Treatment for that is usually just supportive; fluids, humidity. If they have an infection going on, treat them with antibiotics, but mostly just supportive therapy. This is sort of an unusual condition. This is amyloidosis of the larynx in a

Reinkeís edema. Itís fluid in Reinkeís space, which is a potential space under the mucosa of the vocal cord. These patients are almost always smokers. Another word for this is smokers polyps. All this is is just a lot of fluid under the mucosa here. The first thing I try to do is get these patients to stop smoking because again, if you take these off and they continue to smoke, they tend to come back. Used to be that when patients would get these we just take a biopsy forceps and

This is just a plain polyp here. That will not go away on its own. That needs to be excised. The patient will probably return to a normal voice after thatís removed. This just shows an adult screamers nodules, or voice abuse nodules. Same thing. I think the key is, they are always at the same position. Right at the junction of the anterior and middle third of the vocal cord. They are always symmetrical, they are always sort of smooth. They can be different sizes but thatís just a typical appearance. I donít biopsy these because thatís a typical appearance. Thereís nothing to suggest cancer in those. Speech therapy again is the treatment for vocal cord nodules. Any lesion like this is cancer until proven otherwise. Thereís a whole spectrum of disease, including dysplasia, hyperkeratosis, chronic laryngitis, to

Other rare inflammatory diseases that can cause laryngeal problems. This just shows sarcoid of the larynx. Big swollen epiglottis. I just saw a lady like this last week. Usually we try to get the doctor that takes care of their sarcoid to treat them systemically before we do anything about this. The lady that I saw went back to the primary doctor and he treated her. He put her on higher dose steroids and her airway problem got better and this looked better so we ended up not doing anything.

This is rare. This is syphilis of the larynx. This is the epiglottis, syphilitic lesion. Something to think about anyway.

Just to sum up hoarseness: the vast majority of the time is going to be an innocuous problem. Itís going to be related to a URI or voice abuse or reflux. Those are the most common things that I see. But you need to be aware of other problems, such as vocal cord paralysis, cancer, and in kids, things like laryngeal

If we canít achieve a good look at the larynx with that method, usually weíll put them to sleep just to look for a couple of minutes. Just a real short general anesthetic. Look real quick and wake them up. Just to make sure they donít have papillomas or a web or a cyst or something that needs to be