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Hoarseness

Hoarseness. Common referralHoarseness reflects any abnormality of normal phonation. Cartilaginous skeleton. Cricoarytenoid Joint. True synovial joint. Intrinsic Musculature. AbductorsAdductorsTensors. Intrinsic Musculature. Innervation. Abduction. Adduction. Tension. Vocal Fold Anatomy. Laryngeal function.

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Hoarseness

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    1. Hoarseness Kevin Katzenmeyer, MD Byron J Bailey, MD October 24, 2001

    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

    49. Vocal Cysts

    51. Vocal Nodules Usually bilateral Voice rest and speech therapy for 6 months Surgical removal

    53. Vocal cord granulomas LPR Intubation Treat medically

    57. Vocal Cord Paralysis Lesion at nuclear level – cadaveric Lesion above nodose ganglion – abducted Lesion below nodose ganglion - paramedian

    58. Vocal Cord Paralysis Superior laryngeal nerve – subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis

    59. Vocal Cord Paralysis Children Neurologic Traumatic Idiopathic Adults Iatrogenic Traumatic Neoplastic Idiopathic neurologic

    60. Vocal Cord Paralysis

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