Approach of patient with hoarseness of voice

1. Fuad Ridha Mahabot

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. Definition
• the perceived
breathiness quality of
the voice (Bailey)
• a rough or noisy
quality of voice
(Dorland)
• a rough, harsh voice
quality (Stedman)

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. 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. Anatomy of Larynx
• Cartilages of the larynx
✓ unpaired – thyroid cart.,
epiglottis and cricoid
✓ paired – arytenoid,
corniculate and cuneiform
cartilages

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. posterior cricoarytenoid
transverse arytenoid
lateral cricoarytenoid
Vocal cord
Thyroid cart.
Arytenoid cart
Rima glottidis

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. 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. ✓ 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. ✓ 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. 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. • Reinke’s space and the epithelial covering are
responsible for the vocal fold vibration.

15. Physiologic Function
• Prevents aspiration (sphincter)
• Respiratory gateway
• Phonation
• Preventing exhalation – stabilizes thorax
✓ compresses the abdominal cavity during coughing, lifting, and
straining

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. • Currently accepted
mechansim
✓ Interaction of aerodynamic
forces and mechanical
properties of laryngeal
tissues generate vocal
sound

18. Requirements for Phonation
• Adequate breath support
• Approximation of vocal folds
• Favorable vibratory properties
• Favorable vocal fold shape
• Control of length and tension

19. Mechanism of Phonation
• Inhalation of air
• Glottic closure

20. • Exhalation increases subglottic pressure until vocal
folds displace laterally
‘glottal puff’

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. • 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. 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. 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. 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. Causes of hoarseness

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. • 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. • 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. 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. • Rigid Laryngoscopy (70 or 90-degree telescope)
✓ Advantages: best optic image, magnifies, video documentation
✓ Disadvantages: gag, nonphysiologic, expensive

32. • Flexible fiberoptic nasolaryngoscope
✓ Advantages: well tolerated, physiologic, video documentation
✓ Disadvantages: time consuming, expensive, resolution limited
by fiberoptics

33. • Videostroboscopy
✓ Advantages: allows apparent “slow motion” assessment of
mucosal vibratory dynamics, video documentation
✓ Disadvantages: time consuming, expensive

34. • Direct laryngoscopy
✓ Available for use with treatment

35. Benign Vocal Fold Lesions
• Polyps
• Nodules
• Varices and Ectasias
• Cysts
• Granulomas
• Polypoid Corditis/Reinke’s Edema
• Papillomatosis

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. Vocal Polyps

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. vocal nodules

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. vocal fold varices and ectasias

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. vocal fold cysts

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. vocal fold granuloma

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. Reinke’s edema

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. Squamous papillomas