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Approach of patient with hoarseness of voice

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  1. 1. Fuad Ridha Mahabot
  2. 2. Introduction • abnormality in the quality of phonation • often described as being breathy, rough, noisy, and/or harsh • many different conditions that result in hoarseness ✓ share common physiologic pathways leading to the symptom
  3. 3. Definition • the perceived breathiness quality of the voice (Bailey) • a rough or noisy quality of voice (Dorland) • a rough, harsh voice quality (Stedman)
  4. 4. • Dysphonia: Any impairment of voice of difficulty speaking • Dysarthria: Difficulty in articulating words, caused by impairment of the muscle used in speech • Dysarthrophonia: Dysphonia in conjunction with dysarthria, e.g. after cerebrovascular accident, head injury, etc. • Dysphasia: Impairment of the comprehension of spoken and written language (sensory dysphasia), or impairment of the expression by speech or writing (expressive dysphasia)
  5. 5. Symptom –vs- Diagnosis • Hoarseness is a symptom of a disease process • Although hoarseness appears on the ICD9 as a diagnosis (784.49): ✓ it is really a symptom resulting from the underlying disease process ✓ the underlying disease process is your diagnosis (ex. vocal nodules)
  6. 6. Anatomy of Larynx • Cartilages of the larynx ✓ unpaired – thyroid cart., epiglottis and cricoid ✓ paired – arytenoid, corniculate and cuneiform cartilages
  7. 7. • Muscles of the larynx (Intrinsic): ✓ alter size and shape of the inlet • aryepiglottic • oblique arytenoid (assisted by transverse arytenoid and thyroepiglottic muscles) ✓ affect vocal ligaments causing movement or changing their tension • Abductor: posterior cricoarythenoid • Adductor: lateral cricoarythenoid, transverse arytenoids, thyroarythenoid • Tensor: cricothyroid, vocalis
  8. 8. posterior cricoarytenoid transverse arytenoid lateral cricoarytenoid Vocal cord Thyroid cart. Arytenoid cart Rima glottidis
  9. 9. Muscles Origin Insertion Innervation s Main Action Posterior Cricoaryte noid Posterior surface of laminae of cricoid cartilage Muscular process of arythenoid cartilage Recurrent laryngeal nerve Abduct vocal fold Lateral Cricoaryte noid Arch of cricoid cartilage Adduct vocal fold Thyroaryte noid Posterior surface of thyroid cartilage Relaxes vocal fold Interaryte noids One arytenoid cartilage Opposite arythenoid cartilage Close intercartilagenous portion of rima glottidis Vocalis Vocal process of arytenoid cartilage Vocal ligaments Relaxes posterior vocal ligament while maintaining tension of anterior part All intrinsic muscles acting on vocal cord are supplied by recurrent laryngeal n. except for cricothyroid which is supplied by external branch of the superior laryngeal nerve
  10. 10. Vagus nerve: ✓ its branches are responsible for innervation of the larynx ✓ has three nuclei (located within the medulla) • nucleus ambiguous (motor) • dorsal nucleus (parasympathetic) - innervate the involuntary muscles of the bronchi, esophagus, heart, stomach, small intestine, and part of the large intestine • nucleus of the tractus solitarius (sensory) - from the pharynx, larynx, and esophagus.
  11. 11. ✓ emerges from the skull through the jugular foramen ✓ two ganglia - smaller superior ganglion and the larger inferior ganglion ✓ sends small meningeal branches to the dura of posterior fossa ✓ auricular branch - innervates part of the external auditory canal, the tympanic membrane, and skin behind the ear ✓ in the neck - runs behind the jugular vein and carotid artery in the carotid sheath • sends pharyngeal branches to the muscles of the pharynx (except stylopharyngeus) and muscles of the soft palate (except tensor palate)
  12. 12. ✓ superior laryngeal nerve separates from the main trunk of the vagus just outside the jugular foramen • divided into: ▪ internal laryngeal nerve ▪ external laryngeal nerve ✓ recurrent laryngeal nerve • right side ▪ hooks around subclavian artery at root of the neck ▪ then it runs up to ascend along posterior border of trachea and pass under lower border of inferior constrictor • left side ▪ given off in superior mediastinum and recurves around ligamentum arteriosum under arch of aorta
  13. 13. Histology • Epithelial layer ✓ Pseudostratified squamous epithelium superiorly and inferiorly ✓ Nonkeratinizing squamous epithelium at contact surface of medial cord • Subepithelial tissues: three layered lamina propria (based on the amount of elastin and collagen fibers) ✓ Superficial Layer (Reinke’s space) ✓ Intermediate layer ✓ Deep layer • the intermediate and deep layers make up the vocal ligament • Vocalis and thyroarytenoid muscle
  14. 14. • Reinke’s space and the epithelial covering are responsible for the vocal fold vibration.
  15. 15. Physiologic Function • Prevents aspiration (sphincter) • Respiratory gateway • Phonation • Preventing exhalation – stabilizes thorax ✓ compresses the abdominal cavity during coughing, lifting, and straining
  16. 16. Phonation • Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream • Larynx recognized as critical organ for sound production for centuries • Husson presented the neurochronaxic hypothesis in 1950 ✓ Each vibratory cycle caused by separate neural impulse
  17. 17. • Currently accepted mechansim ✓ Interaction of aerodynamic forces and mechanical properties of laryngeal tissues generate vocal sound
  18. 18. Requirements for Phonation • Adequate breath support • Approximation of vocal folds • Favorable vibratory properties • Favorable vocal fold shape • Control of length and tension
  19. 19. Mechanism of Phonation • Inhalation of air • Glottic closure
  20. 20. • Exhalation increases subglottic pressure until vocal folds displace laterally ‘glottal puff’
  21. 21. • Vocal folds return to midline Elastic forces in vocal fold Bernoulli effect of airflow  medial displacement of the medial edges  airflow is stopped
  22. 22. • delay between closure of the lower and upper margins of the fold is termed the phase delay • rapid rise again in subglottic pressure causes the cords to part and the cycle is repeated • escape of small puffs of air that produces the vibratory phenomenon interpreted as sound
  23. 23. Body-Cover Concept ✓ helps to explain mucosal wave ✓ cover - stratified squamous epithelium and the superficial layer of the lamina propria (Reinke’s space) - pliable, elastic, and nonmuscular ✓ body - intermediate and deep layers of the lamina propria (vocal ligament) - more fibrous than the superficial layer • stiffer and has active contractile properties - allow adjustment of stiffness and concentration of the mass ✓ mucosal wave occurs in loose cover ✓ changes in stiffness or tension in the fold alters the mucosal wave •  stiffness in the fold with contraction of the cricothyroid muscle  velocity of the wave   pitch 
  24. 24. Hoarseness • non-specific symptom that can result from a variety of disease processes • can be a manifestation of systemic disease that may affect the larynx • diagnosis can be made in most cases of hoarseness after the TVCs have been adequately examined • “any patient with hoarseness of two weeks duration or longer should undergo visualization of the TVCs…”
  25. 25. Pathophysiology • Loss of approximation – VC paralysis, tumour fixation, tumour coming in between VC • Size of the cord ✓ increase – oedema / tumour ✓ decrease – partial surgical excision / fibrosis • Stiffness ✓ decrease – paralysis ✓ increase – spastic dysphonia / fibrosis
  26. 26. Causes of hoarseness
  27. 27. History Taking • “obtaining a pertinent history is of utmost importance…” • onset, duration, and severity of the dysphonia • potential causes or exacerbating influences - choking episodes, aspiration, stridor, dyspnea, dysphagia, or odynophagia • talkativeness - voice demands at home and at work, recreational singing, and episodes of abuse • other risk factors – tobacco, alcohol, LPR, dehydration, medications, allergies • vocal hygeine - smoking, water intake, caffeine intake, and environmental irritants
  28. 28. • Matheison (2001), Colton & Casper (1990), and Harris (1998) et al – it is important to determine: ✓ nature and chronology of voice prob ✓ exacerbating and relieving factors ✓ lifestyle, dietary and hydration issues ✓ contributing medical conditions or the effects of their Rx ✓ patient’s voice use and requirements ✓ impact on their quality of life, social and psycological well- being ✓ their expectations for outcome of the consultation and treatment
  29. 29. • Patients complaints are most frequently related to: ✓ changes in voice quality ✓ a pitch that is increased or decreased which is appropriate for their age and sex ✓ inability to control their voice as required (e.g. pitch breaks, voice cutting out) ✓ inability to raise the voice of make the voice heard in a noisy environment (reduced loudness) ✓ increased effort or reduced stamina of voice ✓ reduced ability to communicate effectively ✓ difficulty in singing ✓ throat related problems (sore, discomfort, aching) ✓ consequent emotional, psychological effects caused by the above
  30. 30. Physical Examination • begins with a full head and neck examination • examination of larynx – few methods of visualisations Laryngeal mirror ✓ Advantages: fast, inexpensive, minimal equiptment ✓ Disadvantages: gag, nonphysiologic, no permanent image capability
  31. 31. • Rigid Laryngoscopy (70 or 90-degree telescope) ✓ Advantages: best optic image, magnifies, video documentation ✓ Disadvantages: gag, nonphysiologic, expensive
  32. 32. • Flexible fiberoptic nasolaryngoscope ✓ Advantages: well tolerated, physiologic, video documentation ✓ Disadvantages: time consuming, expensive, resolution limited by fiberoptics
  33. 33. • Videostroboscopy ✓ Advantages: allows apparent “slow motion” assessment of mucosal vibratory dynamics, video documentation ✓ Disadvantages: time consuming, expensive
  34. 34. • Direct laryngoscopy ✓ Available for use with treatment
  35. 35. Benign Vocal Fold Lesions • Polyps • Nodules • Varices and Ectasias • Cysts • Granulomas • Polypoid Corditis/Reinke’s Edema • Papillomatosis
  36. 36. Vocal Polyps • present in various sizes, shapes, and composition • sessile / pedunculated; vascular / fibrotic /mixoid • underlying cause - trauma to the superficial lamina propria and microvasculature • commonly located in the middle musculo-membranous region of the vocal fold ✓ shearing and collision forces on the SLP are greatest in this region • videostroboscopy – may determine the involvement of the SLP • primary treatment - surgical excision
  37. 37. Vocal Polyps
  38. 38. Vocal Nodules • vary in size, contour, symmetry, and color • always bilateral • result from vocal abuse or inappropriate vocal use • occur in the anterior two-thirds of the vocal folds • forceful or prolonged vibration of VC  vascular congestion with edema in the submucosa • long-term voice abuse  prolonged edema  hyalinization in the SLP  formation of nodules • voice therapy - primary modality of treatment (minimum 3 months) • surgical excision – if voice therapy fails
  39. 39. vocal nodules
  40. 40. Varices and Ectasias • the result of microvascular trauma within the SLP • located on the superior aspect of the middle musculo- membranous vocal fold - “striking zone” • most prevalent in vocal overdoers (female singers) • voice therapy - primary modality of treatment • surgical Rx - in patients that cannot accept residual vocal symptoms and limitations • surgical Rx - epithelial cordotomies and removing the vessels
  41. 41. vocal fold varices and ectasias
  42. 42. Vocal Fold Cysts • arise in the SLP • present in a variety of sizes • possible to be attached to the vocal ligament • possible cause – voice overuse • classified as mucus retention cysts or epidermoid inclusion cysts ✓ mucus retention cysts arise from plugged mucus glands ✓ epidermoid inclusion cysts result from keratin accumulation in the subepithelial layer
  43. 43. vocal fold cysts
  44. 44. Vocal Fold Granulomas • result from traumatic disruption of the mucosa • classified as being contact granulomas or intubation granulomas ✓ contact granulomas - chronic coughing or throat clearing combined with acid reflux into the posterior larynx ✓ Intubation granulomas - result of intubation, endolaryngeal surgery, rigid bronchoscopy, or other direct laryngeal manipulations • majority are found in the arytenoids region • primary treatment - removing the inciting cause, antireflux, and voice therapy • surgery - last resort - postoperative recurrence frequently occurs
  45. 45. vocal fold granuloma
  46. 46. Reinke’s edema • swelling of SLP • usually located on the superior surface of the musculo- membranous vocal fold • common aetiology - smoking, laryngo-pharyngeal reflux, and vocal abuse • VC - pale, fluid filled compartments attached to the superior surface and margins of the fold • Rx – antireflux, voice therapy, smoking cessation • SurgRx – VC decortication (removal of strip of epithelium)
  47. 47. Reinke’s edema
  48. 48. Squamous papillomas • most common benign neoplasms of vocal cords • commonly located in the musculo-membranous region • variable in size and shape, but may extend into arytenoid, ventricle, subglottis • Surgical treatment ✓ Cold instruments ✓ Microdebrider ✓ Microspot CO2 laser • Resection of lesions inhibits recurrence in 30% of chronic patients
  49. 49. Squamous papillomas