Week 6: Clinical Problem of a Hoarse Voice

1. Week 6: Clinical Problem of a Hoarse Voice Hoarseness results from imperfect phonation due to impairment of normal vocal cord mobility or vibration. It is an important symptom as it may signal a serious cause such as malignancy or a disease with potential for airway obstruction

2. Presentation • It is a common presentation in General Practice, with causes ranging from the very common, trivial, self-limiting conditions, to a life-threatening disorders • 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 So , you call the next patient into your room and as soon as she starts speaking to introduce herself, you notice she has a hoarse voice. Without any further info and before taking a history. What is the most probable diagnoses?????

3. PROBABILITY DIAGNOSIS Viral URTI: acute laryngitis Non-specific irritative laryngitis Vocal abuse (shouting, screaming etc.) Acute tonsillitis Nodules and polyps of cords Phonaesthenia in elderly - ‘tired’ voice In acute hoarseness the diagnosis is usually obvious from the history alone. You ask Mrs X what you can do for her today, and she replies in a hoarse voice “I just came in to get a script for the OCP.” You are concerned by her voice, and are determined to find out more about it. WHAT DO YOU WANT TO ASK IN THE HISTORY TO HELP DETERMINE A DIAGNOSES??

4. History Important to ask: • Nature- Many voice disturbances are typically described by the catch-all term "hoarseness” • Hoarseness is a coarse, scratchy sound • Breathlessness is when the voice feels or sounds weak • Vocal fatigue : loss of control of vocal quality with extended periods of voice use. • Duration of voice complaints • Onset (ie, sudden or gradually progressive) and pattern • Potential triggering/Contributing factors (vocal abuse, concurrent upper respiratory tract infection, change in medications, exposure to known allergens or toxins) • Aggrevating and alleviating factors, such as improvement with voice rest, or fatigue with use • Other respiratory symptoms to indicate URTI- cough, sore throat • Other head and neck symptoms (eg, dysphagia, odynophagia, otalgia) • History of smoking and alcohol use • History of reflux or sinonasal disease • History of past surgery involving the neck (especially thyroid, carotid, and cervical spine), base of skull, or chest • History of trauma or endotracheal intubation • Occupation, hobbies, and habits impacting voice use • Medical comorbidities which may affect voice (eg, rheumatoid arthritis or tremor) The patient is vague and dismissive throughout the history, insisting she only came in to get the script and must get back to work. She eventually agrees to an examination. What are you going to do in the examination?

5. Physical Examination • The physical examination should begin by noting the quality of the patient's voice for yourself • is it actually Hoarseness, breathless or vocal fatigue? • Does it sound wet, gurgling, suggesting salivary pooling? Caused by peritonsillar abscess or supraglottic tumor mass • Does the voice have a whispered quality, or tremor? • Inability to produce any sound is aphonia. • Although not absolutely definitive, various voice qualities may correlate with underlying aetiologies for the voice disorder (too much details) • assess the ear, upper airway mucosa, tongue mobility, cranial nerve function, and respiratory pattern and rate. • Palpate the neck for enlargement of the thyroid gland or cervical nodes. • Systemic diseases should be considered when suggested by symptoms or examination, and include hypothyroidism, and neurologic conditions such as tremor, Parkinson disease, amyotrophic lateral sclerosis, or multiple sclerosis. Having finished the examination, you quickly think to yourself- so now what are some things I don’t want to have missed??

6. SERIOUS DISORDERS NOT TO BE MISSED • Odynophagia • weight loss • history of smoking and alcohol use • (increases risk for laryngeal SCC) • NOTE: Referred ear pain via cranial nerves IX and X may represent one of the first symptoms of laryngopharyngeal cancer. Carcinoma: larynx, lung including laryngeal nerve palsy Imminent airway obstruction (e.g. acute epiglottitis, croup) Other rare severe infections (e.g. tuberculosis, diphtheria) Foreign body Motor neurone disease Myaesthenia gravis RED flag for underlying malignancy, (when not associated with an UTRI) shortness of breath Stridor Cough Hemoptysis throat pain Dysphagia

7. Case Cont: • Turns out the patients voice has been ‘husky’ for a few months now, she thinks it came on gradually, it is not painful and she has not noticed any other symptoms • On examination, you found no abnormalities. • Does this hoarseness warrant further investigation?

8. When to Investigate further? • Acute cases that are unexplained, fail to respond by 3 - 4 weeks or recur. • All chronic cases > 3weeks. • Any case with stridor or non-tender cervical lymphadenopathy. • Chronic hoarseness must be investigated to exlude: • Carcinoma of the larynx • Non-malignant vocal cord lesions include polyps, vocal nodules, contact ulcers, granulomas, other benign tumours and leucoplakia • The most common diagnosis is still: • children – overuse ‘screamer's nodules’ • adults - non-specific irritant laryngitis What particular investigations are you going to do?

9. INVESTIGATIONS The following need to be considered: • Thyroid function tests. • Chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy. • The choice of imaging to detect suspected neoplasia or laryngeal trauma is special CT scan, although is not a substitute for direct laryngeal visualisation. REFER to ENT • Chronic Hoarseness >3week, in the absence of symptoms of an acute respiratory infection • Patients with associated symptoms concerning for malignancy • ENT consult should include: • complete head and neck examination of the laryngopharynx, with visualization of the true and false vocal cords and epiglottis, via laryngoscopy

10. TREATMENT Acute hoarseness • Treat according to cause. • Advise vocal rest or minimal usage at normal conversation. • 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 and treat accordingly • Consider referral to ENT specialist.

11. PITFALLS • Toxic fumes • Vocal abuse • Benign tumours of vocal cords (e.g. polyps, ‘singers’ nodules, papillomas) • Gastro-oesophageal reflux → pharyngolaryngitis • Goitre • Dystonia • Physical trauma (e.g. post-intubation), haematoma • Fungal infection (e.g. Candida with steroid inhalation, immunocompromised) • Allergy (e.g. angioedema) • Leucoplakia

12. MASQUERADES Consider: - drugs: antipsychotics, anabolic steroids - smoking →non-specific laryngitis • hypothyroidism, acromegaly Is the patient trying to tell me something? Rarely, hoarseness can be a functional or deliberate symptom referred to as ‘hysterical aphonia’. In this condition, patients purposely hold the cords apart while speaking. • functional aphonia • functional stridor

13. References • Murtaghs • Up-to-date