Chapter 57: Hoarseness

Hoarseness (dysphonia) is defined as an altered voice due to a laryngeal disorder.² It is an important symptom of laryngeal disease presenting in general practice, and ranges from the very common, trivial, self-limiting condition of viral upper respiratory tract infection to a life-threatening disorder (see TABLE 57.1). It may be of sudden presentation lasting only a few days or develop gradually and persist for weeks or months. The cut-off point between acute and chronic hoarseness is three weeks duration, by which time most self-limiting conditions have resolved. Hoarseness pertains to harsh, raspy, gravelly or rough tones of voice rather than pitch or volume. Rarely, hoarseness can be a functional or deliberate symptom referred to as ‘hysterical aphonia’.³ In this condition, patients purposely hold the cords apart while speaking.

History

Note the nature and duration of the voice change. Inquire about corticosteroid inhalations, excessive or unaccustomed voice straining (especially singing), recent surgery, possible reflux, smoking or exposure to environmental pollutants. Elicit associated respiratory or general symptoms such as cough and weight loss. Consider symptoms of hypothyroidism.

Examination

Palpate the neck for enlargement of the thyroid gland or cervical nodes. Perform a simple oropharyngeal examination except if epiglottitis is suspected. Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and mental slowing. Perform indirect laryngoscopy if skilled in the procedure.

Investigations

The following need to be considered:

• Thyroid function tests.

• Chest X-ray if it is possibly due to lung cancer with recurrent laryngeal nerve palsy.

• Indirect laryngoscopy (the gag reflex may preclude this).

• Direct laryngoscopy with a flexible fibre-optic endoscope with possible biopsy (the most sensitive investigation).

• The choice of imaging to detect suspected neoplasia or laryngeal trauma is special CT scan.

Management principles

Acute hoarseness

• Treat according to cause.

• Advise vocal rest or minimal usage at normal conversational level.

• Avoid irritants (e.g. dust, tobacco, alcohol).

• Consider inhalations and cough suppressants in cases of acute URTI and coughing paroxysms.

Chronic hoarseness

• Establish the diagnosis.

• Consider referral to ENT specialist.

• It is worth bearing in mind that stridor in infants can be caused by a congenital abnormality of the larynx, including laryngomalacia (congenital laryngeal stridor), which is particularly noticeable when the child is asleep; laryngeal stenosis (congenital laryngeal narrowing); and laryngeal paralysis due to birth trauma of the vagus nerve. Vocal cord paralysis/palsy is the most common laryngeal abnormality in children (20% of cases) after laryngomalacia.³

• In children exclude the acute infections—laryngotracheobronchitis (croup), tonsillitis and epiglottitis.

• Persistent hoarseness in children is due commonly to vocal cord nodules related to vocal abuse, such as screaming and yelling, often due to noisy children’s games.

• It is important to exclude a juvenile papilloma in a hoarse child.⁴

Acute laryngitis

Most cases are caused by the respiratory viruses—rhinovirus, influenza, para-influenza, Coxsackie, adenovirus and respiratory syncytial virus, resulting in vocal cord oedema (be cautious of group A Streptococcus). The main symptom is hoarseness, which usually persists for 3–14 days and leads to loss of voice. Even speaking can be painful. Aggravating factors include smoking, excessive alcohol drinking, and exposure to irritants and pollutants, air-conditioning systems and very cold weather.

Management

• Rest at home, including voice rest (the best treatment).

• Use the voice sparingly, avoid whispering.

• Use a warm sialagogue (e.g. hot lemon drinks).

• Drink ample fluids, especially water.

• Avoid smoking, passive smoke and alcohol.

• Have hot, steamy showers as humidity helps.

• Use steam inhalations (e.g. 5 minutes, three times a day).

• Use cough suppressants, especially mucolytic agents.

• Use simple analgesics, such as paracetamol or aspirin, for discomfort.

• Antibiotics are of no proven use unless there is evidence of bacterial infection. Corticosteroids are rarely indicated.

Chronic laryngitis: ‘barmaid syndrome’

This typically occurs in a heavy smoker who works in a heavy smoking environment, who is a heavy drinker and continually talks or sings. It is a combination of vocal abuse and chemical irritation. Hoarseness often comes and goes. Treatment involves modification of these factors and screening for vocal cord tumours.

Chronic laryngitis due to laryngopharyngeal reflux is treated with an 8–12 week empirical course of proton-pump inhibitors as well as dietary and lifestyle modification.²

Benign tumours of the vocal cords

These include nodules (most common) (see FIG. 57.1), polyps (second most common), cysts and papules. Vocal cord nodules, including ‘singer’s nodules’, may respond well to conservative measures such as voice rest and vocal therapy. If not, they can be removed by microlaryngeal surgery or laser therapy. Dependent polyps and papillomas are removed by microsurgery.

Laryngeal cancer

Squamous cell carcinoma usually occurs in patients with a history of chronic laryngitis, smoking and alcohol use. Symptoms include hoarseness, stridor, haemoptysis and dysphagia. It may be preceded by leucoplakia, which is treated by vocal cord stripping under microsurgery. The diagnosis based on persistent hoarseness is made after fibre-optic laryngoscopy and biopsy by a specialist. The patient may present with an unexplained cervical lymph node. The condition is curable if detected early. Small local tumours can be treated by radiotherapy or laser therapy. Larger tumours usually require laryngectomy and perhaps dissection of the cervical lymph nodes (commando operation). Such radical surgery demands considerable patient support, including education about speech, eating and tracheostomy care.

Vocal cord dysfunction⁶

This condition is paradoxical vocal (or fold) adduction on inspiration and abduction on expiration, causing inspiratory airway obstruction and stridor. It tends to be misdiagnosed as asthma. Apart from dyspnoea and stridor (usually inspiratory) and wheezing, symptoms may include intermittent hoarseness, chest and/or throat tightness, a noisy rasping sound and a choking or suffocating sensation. Patients may complain about a feeling ‘like breathing through a straw’. Diagnosis is by observing inspiratory closure of the vocal cords with direct laryngoscopy. The mainstay of treatment is speech therapy.

Excessive dynamic airways collapse (‘floppy trachea’)⁷

Also known as adult tracheobronchomalacia, this is defined as pathological collapse and narrowing of the airway lumen by ≥50%. It is due to laxity of the posterior membrane into the airway lumen (in the presence of structurally intact cartilage) during forced expiration. Symptoms include breathing difficulty, coughing, difficulty clearing secretions, dyspnoea and stridor. Respiratory failure and death can occur. Diagnosis is with CT scanning and fibre-optic bronchoscopy. Treatment varies from conservative to surgery (minimal to radical). Refer to a respiratory physician.

• Acute cases that are unexplained, fail to respond by 3–4 weeks or recur.

• All chronic cases.

• Any case with stridor or non-tender cervical lymphadenopathy.

• Patients requiring voice therapy when vocal abuse is identified.