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Hoarseness

Hoarseness. Hoarseness. Common referral Hoarseness reflects any abnormality of normal phonation. Cartilaginous skeleton. Cricoarytenoid Joint. True synovial joint. Intrinsic Musculature. Abductors Adductors Tensors. Intrinsic Musculature. Innervation. Abduction. Adduction. Tension.

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Hoarseness

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  1. Hoarseness

  2. Hoarseness • Common referral • Hoarseness reflects any abnormality of normal phonation

  3. Cartilaginous skeleton

  4. Cricoarytenoid Joint • True synovial joint

  5. Intrinsic Musculature • Abductors • Adductors • Tensors

  6. Intrinsic Musculature

  7. Innervation

  8. Abduction

  9. Adduction

  10. Tension

  11. Vocal Fold Anatomy

  12. Laryngeal function • Sphincteric function • Respiration • Phonation • Other • Stabilizes the thorax by preventing exhalation during lifting • Compresses abdominal cavity during coughing or straining

  13. Phonation • Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream • Pitch • Quality • Volume

  14. Sound Production • Contraction of expiratory muscles • Rise in subglottic air pressure • Escape through glottis • Closure • Bernoulli effect • elasticity

  15. Phonation • Glottal puff • Release of air as upper margins of TVC separate • Phase delay • Delay of closure between upper and lower margins of TVC • Mucosal wave • Horizontal and vertical components

  16. Mucosal wave/Phase delay

  17. Body-Cover Theory • Changes to mucosal wave • Stiffness • tension

  18. Mucosal wave • Velocity increases • Increased airflow • Increased subglottic pressure

  19. Fundamental Frequency • Pitch (measure in Hertz) • Changes in vibration frequency • Mass • Stiffness • viscosity

  20. Workup • “Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords”

  21. Workup • History • Physical Examination • Ancillary tests

  22. History • URI • Laryngitis • Overuse with edema and inflammation • Paralyses • Granulomas from coughing

  23. History • Trauma • Arytenoid dislocation • Nerve paralysis • Laryngeal fractures • Mucosal lacerations

  24. History • Intubation • Arytenoid dislocations • Nerve injury • granulomas

  25. History • Pulmonary conditions – power source • COPD • Asthma

  26. History • Gastrointestinal • LPR • Autoimmune • RA • Endocrine • Hypothyroidism

  27. Neurologic disorders

  28. Surgical History • Skullbase procedures • Carotid endarterectomies • Thyroidectomies • Aortic aneurysm repairs

  29. Medications

  30. Social History • Tobacco • Alcohol • ?Inflammation • ?Drying of secretions • ?malignancy

  31. Occupational History • Voice abuse

  32. Associated Symptoms

  33. Physical Examination • Head & neck examination • Laryngeal examination • Physiologic position • Image quality • Magnification • Cost • Required equipment • Time/skill necessary

  34. Laryngeal examination • Indirect mirror • Flexible laryngoscopy • Rigid laryngoscopy

  35. Indirect mirror examination • Advantages • Quick • Inexpensive • Little equipment • Disadvantages • Gag • Anatomic features • nonphysiologic

  36. Flexible laryngoscopy • Advantages • Well tolerated • Complete examination • Video documentation • Disadvantages • More time • Expensive

  37. Rigid laryngoscopy • Advantages • Best images • Magnification • Video documentation • Disadvantages • Expensive • Nonphysiologic • Gag • Anatomic features

  38. Videostroboscopy • Light quasi-synchronized with vocal fold vibrations • Bell microphone • Electroglottography • Video recording • Detailed review • Comparison after treatment

  39. Videostroboscopy • Synchronous = motionless • Asynchronous = slow motion

  40. Videostroboscopy • Vocal fold closure pattern • Vocal fold vibratory pattern • Mucosal wave of each vocal fold • Symmetry

  41. Videostroboscopy

  42. Radiographic studies • MRI • CT

  43. Laryngeal EMG • Myopathy – normal frequency of firing but decreased amplitude • Neuropathy – decreased frequency but occasional normal amplitudes • Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun

  44. Laryngeal EMG

  45. Differential • Congenital • Inflammatory • Neoplastic • Traumatic • Neurologic • Endocrine • Iatrogenic • Local factors

  46. Vocal Cysts

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