DEFINATION
ATIOPATHOGENESIS
FEATURE AND PREDISPOSING FACTER
SYMPTOMS
DIAGNOSIS
DEFFERENTIAL DIAGNOSIS
TREATMENT
Also known as Singer’s or Screamer's Nodes
Vocal cord nodules are benign growths on both vocal cords that are caused by vocal abuse
They appear symmetrically on the free edge of vocal cord
At the junction of anterior 1/3 and posterior 2/3 *area of maximum vibration of vocal cord.
4. HOARSENESS
Hoarseness is defined as change in voice quality or roughness of voice resulting from
variations of periodicity and/or intensity of consecutive sound waves.
Hoarseness is a symptom and not a disease
For production of normal voice, vocal cords should:
1. Be able to approximate properly with each other.
2. Have a proper size and stiffness.
3. Have an ability to vibrate regularly in response to air column.
Any condition that interferes with the above function causes
hoarseness.
6. CLINICAL EVALUATION OF HOARSENESS
History should includes the following:
Duration of voice complaints
Character of onset (ie, sudden or gradually progressive) and pattern (ie, worse with voice use or worse in the morning upon arising)
Potential triggering factors (vocal abuse, concurrent upper respiratory tract infection, change in medications, exposure
to known allergens or toxins)
Exacerbating and relieving factors, such as improvement with voice rest, or fatigue with use
Other head and neck symptoms (eg, dysphagia, otalgia, odynophagia, bleeding. postnasal drip)
History of reflux or sinonasal disease
History of smoking and alcohol use
History of past surgery involving the neck (especially thyroid, carotid, and cervical spine), base of skull, or chest
History of trauma or endotracheal intubation
Medical comorbidities which may affect voice (eg. rheumatoid arthritis or tremor)
7. CLINICAL EVALUATION
5. Direct laryngoscopy and micro laryngoscopy help in detailed examination, biopsy of the lesions and
assessment of the mobility of cricoarytenoid joints
6. Bronchoscopy and oesophagoscopy may be required in cases of paralytic lesions of the cord to exclude
malignancy
2. Indirect laryngoscopy. Many of the local laryngeal causes can be diagnosed.
3. Examination of neck, chest, cardiovascular and neurological system would help to find cause for laryngeal paralysis.
4. Laboratory investigations and radiological examination should be done as per dictates of the cause suspected on
clinical examination.
8. 1-DYSPHONIA PLICAVENTRICULARIS
(VENTRICULAR DYSPHONIA)
Here voice is produced by ventricular folds (false cords) which have taken over the function
of true cords.
It is due to impaired function of true vocal cord and may be functional (cause is
psychogenic).
Voice is rough, low-pitched and unpleasant
OTHER CAUSES
9. 2-FUNCTIONAL APHONIA
(HYSTERICAL APHONIA)
Aphonia is usually sudden and unaccompanied by other laryngeal
symptoms.
Patient communicates with whisper
On examination, vocal cords are seen in abducted position and fail
to adduct on phonation; however, adduction of vocal cords can be
seen on coughing, indicating normal adductor function.
10. 3-PUBERPHONIA
(MUTATIONALFALSETTO VOICE)
Normally, childhood voice has a higher pitch. When the larynx matures at puberty, vocal
cords lengthen and the voice changes to one of lower pitch this feature exclusive to males.
It is seen in boys who are emotionally immature, feel insecure and show excessive fixation
to their mother.
(Gutzmann’s pressure test)
Pressing the thyroid prominence in a backward and downward direction relaxes the overstretched
cords and low tone voice can be produced
11. 4-PHONASTHENIA
It is weakness of voice due to fatigue of phonatory muscles. Thyroarytenoid and
interarytenoids or both may be affected.
Treatment is voice rest and vocal hygiene, emphasizing on
periods of voice rest after excessive use of voice
5-DYSPHONIA
Dysphonia can be divided into three types:
1- Adductor
2- abductor
3- mixed
12. ADDUCTOR DYSPHONIA
The adductor muscles of larynx go into spasm causing vocal cords
to go into adduction.
It is due to spasms of posterior cricoarytenoid muscle (the only
abductor) and thus keeping the glottis open. Patient gets a breathy
voice or breathy breaks in voice
ABDUCTOR DYSPHONIA
MIXED DYSPHONIA
14. VOCAL NODULES
Also known as Singer’s or Screamer's Nodes
Vocal cord nodules are benign growths on both vocal cords that are caused by vocal abuse
They appear symmetrically on the free edge of vocal cord
At the junction of anterior 1/3 and posterior 2/3 *area of maximum vibration of vocal cord.
15. AETIOPATHOGENESIS
Due to vocal trauma when person speaks in unnatural low tones for prolonged periods or
at high intensities
Common in teachers, actors, vendors, pop singers, talkative children
Vocal abuse edema and hemorrhage in the submucosal space hyalinization,
fibrosis, hyperplasia of epithelium Nodule.
16. FEATURES
Speaking activity i.e. singing, teaching.
thyroid disease.
Smokers.
caffeine use
Lower vocal hygiene.
PREDISPOSING FACTER
Soft, reddish and edematous swellings (early stages)
Greyish / white (later stages)
Size : Pin-head to half a pea
17. SYMPTOMS
Hoarseness of voice.
Vocal fatigue.
Pain in neck.
DIAGNOSIS
Indirect laryngeal examination
Direct laryngeal examination
Endoscopic examination
18. TREATMENT
CONSERVATIVE;
Keep away from predisposing factors
proper use of voice.
Maintain vocal hygiene and adequate hydration.
Use of Antibotics,steroids to subside infections.
SURGICAL;
Excision by Micro-laryngeal surgery.
Laser.
POSTOPERATIVE
Speech therapy and re-education in voice production (to prevent
recurrence).
19. VOCAL POLYPS
Result of vocal abuse or misuse
Mostly affects men in age group of 30-50
Typically its unilateral and arising from same position as vocal nodule
Its soft smooth and often pedunculated
It may flop up and down during phonation or respiration
Its caused by sudden shouting resulting in hemorrhage in the vocal cord and subsequent submucosal
edema.
20. SYMPTOMS
Hoarseness is a common symptom
Large polyp may cause dyspnea, stridor or intermittent choking
Some patients may complain of diplophonia due to different
vibratory frequencies of two vocal cords
Treatment:
surgical excision under operating microscope and speech therapy
21. VOCAL GRANULOMA OR CONTACT ULCER
Due to faulty voice production
Vocal process of arytenoid cartilage hammer against each other
resulting in ulceration and granuloma formation
Some cases are due to laryngopharyngeal reflux
hoarseness, constant desire to clear the throat and pain in
the throat which worsens on phonation
Examination reveals unilateral or bilateral ulcers with
congestion of arytenoid cartilages
SYMPTOMS
Antireflux therapy.
Speech therapy
Inhaled steroids or intralesional injection of steroid to correct
inflammation
Micro laryngeal surgery
MANAGEMENT
22. VOCAL CORD MALIGNANCY
Except for laryngeal papilloma which constitute about 80% of the total occurrence of neoplasms
of the larynx, others are uncommon.
SQUAMOUS PAPILLOMAS They can be divided into
(i) juvenile and (ii) adult-onset
CHONDROMA
HAEMANGMAIO
GRANULAR CELLTUMOUR
GLANDULARTUMOURS
RARE BENIGN TUMOUR OF LARYNX
Hoarseness or aphonia with respiratory difficulty or even stridor and dysphagia.
Diagnosis is made by flexible fibreoptic laryngoscopy,
direct laryngoscopy and biopsy.
SYMPTOMS
23. SPECIFIC QUESTIONS FOR HISTORY
Mode of onset
Duration of illness
Associated symptoms
Difficulty in speech?
Difficulty in eating
Pain in throat
Any similar previous history
Aggravating and relieving factors
Patient's occupation
Habits i.e. smoking
25. A 32-year-old male, teacher by profession comes to the OPD with complains of
change in voice for past 4 months. Initially the voice became hoarse when he
used to take frequent classes but now the hoarseness has become permanent.
On fibreoptic examination of larynx, you find smooth rounded elevations on mid
one third of both vocal cords apposing each other when patient tries to speak.
What specific question you would ask in history to elicit the diagnosis?
Give your differential diagnosis.
Give management plan of most probable diagnosis.
Differentiate between vocal nodules, vocal polyps, vocal cord granulomas and vocal cord malignancy?
Discuss the preventive measures in such a condition. What are the aggravating factors?
Write prescription for this patient
CBL-17