Hoarseness Mucosal Vocal Fold Lesions Paresis and LPR

1. Hoarseness Mucosal Vocal Fold Lesions Paresis and LPR Melanie Giesler, DO

2. Hoarseness • Symptom and disease – symptom of disease process and is an ICD9 code • the perceived breathiness quality of the voice (Bailey) • a rough or noisy quality of voice (Dorland) • a rough, harsh voice quality (Stedman)

3. Anatomy: Laryngeal Cartilage

4. Anatomy: Laryngeal Muscles

5. Anatomy: Laryngeal Muscles

6. Anatomy: Laryngeal Innervation

7. Anatomy: Laryngeal Motion • Tension of vocal ligament

8. Anatomy: Laryngeal Motion • Adduction of vocal ligament

9. Anatomy: Laryngeal Motion • Abduction of vocal ligament

10. Histology

11. History • Onset and duration of vocal symptoms • Potential causes or exacerbating influences • Other risk factors • Tobacco • Alcohol • LPR • Dehydration • Medications • Allergies • Voice Abuse – one episode or chronic – teachers/preachers • Neurologic Disorders • History of Trauma/Surgery

12. Physical Examination • Flexible fiberoptic nasolaryngoscope • Advantages: well tolerated, physiologic, video documentation • Disadvantages: time consuming, expensive, resolution limited by fiberoptics

13. Physical Examination • Videostroboscopy • Advantages: allows apparent “slow motion” assessment of mucosal vibratory dynamics, video documentation • Disadvantages: time consuming, expensive

14. Benign Vocal Fold Lesions • Polyps • Nodules • Varices and Ectasias • Cysts • Granulomas • Polypoid Corditis/Reinke’s Edema • Papillomatosis

15. Polyps

16. Polyps

17. Nodules

18. Varices and Ectasias

19. Cysts

20. Granulomas

21. Polypoid Corditis (Reinke’s Edema) • Extensive swelling of SLP • Usually on superior surface of musculo-membranous vocal fold • Typically bilateral but asymmetric volume • Multifactorial cause • Smoking • LPR • Vocal hyperfunction

22. Polypoid Corditis (Reinke’s Edema) • Treatment • Smoking cessation • Antireflux medication • Preoperative vocal therapy • Surgery • Epithelial microflap elevation with SLP contouring and reduction using either cold instruments, Microspot CO2 laser, or both • Vocal ligament should never be visualized • Both vocal folds can be treated in one procedure if flap is elevated on superior surface of vocal fold

23. Polypoid Corditis (Reinke’s Edema)

24. Papillomatosis • Human papillomavirus 6 and 11 • Confined to epithelium • Excision should preserve SLP • Most commonly found in musculo-membranous region, but may extend into arytenoid, ventricle, subglottis

25. Papillomatosis • Surgical treatment • Cold instruments • Microdebrider • Microspot CO2 laser • Resection of lesions inhibits recurrence in 30% of chronic patients

26. Papillomatosis

27. Vocal Cord Paralysis

28. Etiology • Causes of Vocal Cord Paralysis in Adults: Benninger et al., Evaluation and Treatment of the Unilateral Paralyzed Vocal Fold. Otolaryngol Head Neck Surg 1994;111-497-508

29. Evaluation - Electromyography • Normal • Joint Fixation • Post. Scar • Fibrillation • Denervation • Polyphasic • Synkinesis • Reinnervation

30. Evaluation - Imaging • Chest X-ray • Screen for intrathoracic lesions • MRI of Brain • Screen for CNS disorders • CT Skull Base to Mediastinum • Direct Laryngoscopy • Palpate arytenoids, especially when no L-EMG

31. Laryngopharyngeal Reflux (LPR) • Other aliases: extraesophageal reflux, reflux laryngitis, posterior laryngitis • Contributes up to 50% of laryngeal complaints • Backflow of gastric contacts into larynx, pharynx, and upper aerodigestive tract • Upper esophageal sphincter (UES) dysfunction • Affects 50 million Americans • Present in 4-10% of those with gastroesophageal reflux disease (GERD) • About 20-70% with LPR have symptoms of GERD

32. Upper Esophageal Sphincter • C-shaped sling attached to cricoid cartilage • Cricopharyngeus • Thyropharyngeus • Proximal cervical esophagus • Innervated by pharyngeal plexus • Vagus nerve • Superior laryngeal nerve • Recurrent laryngeal nerve • Glossopharyngeal nerve • Sympathetics from superior cervical ganglion

33. Key Symptoms • Cervical dysphagia • Globus • Respiratory complaints • Sore throat • Chronic cough • Throat clearing • Dysphonia • Hoarseness • Upright (daytime) reflux • Heartburn uncommon • Normal acid clearance

34. Comparison to Gastroesophageal Reflux • Cervical dysphagia • Globus • Respiratory complaints • Sore throat • Chronic cough • Throat clearing • Dysphonia • Hoarseness • Upright (daytime) reflux • Heartburn uncommon • Normal acid clearance • Dysphagia • Less respiratory complaints • Rare dysphonia • Supine (nighttime) reflux • Heartburn • Delayed acid clearance • Regurgitation • Esophagitis

35. Other Symptoms • Asthma exacerbation • Ear pain • Excess throat mucus • Halitosis • Laryngospasm • Neck pain • Odynophagia • Postnasal drip • Voice complaints • Breaks • Fatigue • Longer warmup time • Loss of upper singing range

36. Physical Findings (Belafsky et al, 2001) • Posterior laryngitis • Edema • Posterior commissure and arytenoids • Increased vascularity • Erythema • Edema • Infraglottic (pseudosulcus vocalis) • Diffuse • Ventricular effacement • Mucosal hypertrophy • Laryngeal pachydermia (granularity, cobblestone) • Ulcers, granulomas, scarring, stenosis

37. Implications • Laryngomalacia • Laryngospasm • Laryngotracheal stenosis • Obstructive sleep apnea • Otitis media • Paradoxical vocal-fold motion disorder • Recurrent croup • Reinke edema • Ulceration • Vocal fold granulomas Asthma Bronchiectasis Cervical dysphagia Chronic cough Chronic dysphonia Chronic laryngitis Chronic rhinitis Dental caries Globus pharyngeus Laryngeal carcinoma Laryngeal papillomas

38. Pediatric Considerations • Otitis media/otalgia • Recurrent upper respiratory infections • Regurgitation/vomiting • Rhinorrhea • Sleeping disorders • Subglotticstenosis • Sinusitis • Torticollis (Sandifer’s Syndrome) Abnormal crying Anorexia Apnea Chronic cough Chronic nasal pain Dental erosion Dysphagia Irritability Laryngomalacia Nasal obstruction

39. Diagnosis • Ambulatory 24-hour double-probe pH monitoring • Current standard • Probes above upper and lower esophageal sphincters • Detects acidic reflux events only • Impedence • Multiple electrode pairs on pH-probe-type catheter • Track retrograde bolus transit • Measures acidic and nonacidic events • No set guidelines lead to controversy and misdiagnoses • Edema, ventricular effacement, and pseudosulcus vocalis are more common findings • Physicians commonly look for posterior laryngitis